Chapter 4 Cognitive-Behavioral Theory Paula S. Nurius and Rebecca J. Macy Overarching Question: How can human beings think about their thinking to create therapeutic change in their thoughts, feelings, and behaviors? Copyright © 2012. John Wiley & Sons, Incorporated. All rights reserved. Relevance to Contemporary Practitioners Social workers and practitioners from allied disciplines use interventions based on cognitive-behavioral theory (CBT) to address a wide range of psychosocial problems, including depression, anxiety, chronic pain, substance abuse, violent trauma, and difficult family relationships (J. S. Beck, 2011; Berlin, 2002; Iverson et al., 2011; Nurius, 2008; O’Donohue & Fisher, 2009; Ronen & Freeman, 2007). Cognitive-behavioral therapy (CBT) has been applied and found effective with an array of clients from a range of socioeconomic and sociocultural backgrounds (Hays & Iwamasa, 2006; Koh, Oden, Munoz, Robinson, & Leavitt, 2002; Voss Horrell, 2008), LGBTQ populations (Martell, Safren, & Prince, 2004), and a range of developmental ages including youth (Christner, Stewart, & Freeman, 2007; Lecroy, 2008; Manassis, 2009; Weisz & Kazdin, 2010) and older adults (Laidlaw, Thompson, Dick-Siskin, & Gallagher-Thompson, 2003; Lau & Kinoshita, 2006). In addition, CBT can be used in a variety of settings, from private practice offices to inpatient hospitals to community outreach services (e.g., A. Nezu & Nezu, 2010). Over the course of its development, the underlying cognitivebehavioral theory has been subjected to extensive research. These research results are a highly favorable body of findings that show the therapeutic effectiveness of CBT and its theoretical foundations (A. T. Beck, 2005). The results of one recent meta-analytic study recommended CBT as a ‘‘first-line psychosocial treatment of choice’’ for clients with anxiety and depressive disorders (Tolin, in press). Another strength of the theory base is its considerable versatility and adaptability. As social work professionals are increasingly asked to use evidence-based practices and to 125 Dulmus, Catherine N., et al. Human Behavior in the Social Environment : Theories for Social Work Practice, John Wiley & Sons, Incorporated, 2012. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ncent-ebooks/detail.action?docID=980956. Created from ncent-ebooks on 2020-05-23 15:48:28. Copyright © 2012. John Wiley & Sons, Incorporated. All rights reserved. 126 Human Behavior in the Social Environment show that their interventions make a difference in the lives of the people with whom they work, many practitioners turn to cognitive-behavioral therapy because of the combination of its utility, adaptability, and strong record of effectiveness (Macy, 2006). Cognitive-behavioral therapy has at its foundation a set of welldocumented and detailed intervention techniques (see, e.g., J. S. Beck, 2011; Leahy, 2002) that are widely available and straightforwardly applied. Such clear-cut application is particularly salient to practitioners. CBT’s emphasis on articulating implementation methods provides a basic template for how to translate theory into therapeutic practice. Nonetheless, the effectiveness of any therapeutic method can be diluted by adherence to technique that is insufficiently attentive to the characteristics, complexities, and context of any given case. Grounding in the underlying theory, awareness of emerging developments, and balanced attention to limitations as well as strengths of this model of practice are essential to making decisions about the appropriateness of CBT for a given client as well as adaptation to foster good fit. As with any intervention, the effectiveness of cognitive-behavioral therapy is dependent on the practitioner’s ability to use the theory and related techniques in clearly formulated, deliberate, and thoughtful ways. Practitioners will be most effective in their use of cognitive-behavioral interventions if they have a nuanced understanding of the theoretical premises and are skilled in a range of CBT intervention techniques and tools. This level of mastery requires study, practice, and supervision from others well versed in this intervention theory. In addition, effective application of cognitive-behavioral interventions is incumbent on the social worker’s ability to appropriately adapt and modify cognitive-behavioral theory and therapy techniques to clients’ sociocultural and socioeconomic backgrounds, as well as clients’ development in the life course (Cormier, Nurius, & Osborn, in press; Hays & Iwamasa, 2006). To provide readers with a theoretical foundation for using this therapy effectively in assessment and intervention, we provide an overview of the theory and its developmental history, basic and advanced theoretical principles, and recent developments and critiques. Overview of Cognitive-Behavioral Theory The cognitive-behavioral theoretical framework of human functioning is based on the premises that thoughts, emotions, and behaviors are inextricably linked and that each of these aspects of human functioning continuously effects and influences the others. Cognitive-behavioral theory posits that thoughts about the self, relationships, the world, and the future shape emotions and behaviors. Feelings and behaviors shape thoughts and thought processes in a kind of ongoing reciprocal feedback loop. Moreover, cognitive-behavioral theory posits that cognitive-affectivebehavioral processes are similar and analogous across human beings and Dulmus, Catherine N., et al. Human Behavior in the Social Environment : Theories for Social Work Practice, John Wiley & Sons, Incorporated, 2012. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ncent-ebooks/detail.action?docID=980956. Created from ncent-ebooks on 2020-05-23 15:48:28. Copyright © 2012. John Wiley & Sons, Incorporated. All rights reserved. Cognitive-Behavioral Theory human experience. However, the content within the cognitive-affectivebehavioral processes is specific, unique, and personal to the individual (Alford & Beck, 1997; DeRubis, Tang, & Beck, 2010). This distinction is critically important. There is a lot yet to learn about processes—how exactly thoughts and feelings interact with each other as well as with genetics, physiology, and prior lived experience, and how these systematically relate to and with behavior. Yet to date, it appears that there is a high degree of comparability in how processes operate as with other aspects of the human body and functioning. The defining content of memories, beliefs, understandings, expectations, and values can be highly variable, reflecting differences across people. These differences flow into the operating system of cognition–affect–body–behavior processes in a continuous reciprocal interchange to generate an intricate, contextualized set of thoughts, feeling and behaviors. In other words, how human beings construct the reality of their lives and the meaning human beings give to their lives, their selves, their relationships, their environments, and their futures is distinct. This distinctiveness comes from uniquely individual experience, knowledge, and memory. When this cognitive-affective-behavioral system works well, human beings are able to take in information from their experiences and their environment, process and manage that information, and then use the information to direct emotions and behaviors toward meeting their needs and goals in ways that are adaptive, efficient, and functional. However, serious difficulties in human thinking, feeling, behaving, and functioning can occur when there are problems in thoughts and thought processes (J. S. Beck, 2011). Central to cognitive-behavioral theory is the notion of cognitive mediation—that the meaning people bring to and take from their experiences shapes how they feel and respond. Accordingly, our cognitive activity is an active and crucial part of both positive and negative functioning. When our emotions and behaviors are guided by thoughts and beliefs that are seriously unhelpful in some manner, it is likely that we will have difficulty meeting our needs, pursuing our goals, and experiencing life in a satisfied, comfortable manner. When our needs are unmet and goals are not achieved, we are then likely to experience distress and anguish. In turn, these negative feelings will reinforce or create new problems in our thoughts and beliefs, our emotional and social experience, as well as our views of ourselves and what the future holds. As a counterpoint to this, cognitive-behavioral theory also posits that we human beings have the capacities to monitor, examine, and change our thoughts, beliefs, and thought processes. We have the ability to think about thinking, and thus we have the capacity to alter and replace problematic, inaccurate, or in some other way unhelpful thoughts. By directing attention to and modifying thoughts and beliefs, we can also change and direct emotions and behaviors to better meet our needs and goals toward more beneficial outcomes (Leahy, Tirch, & Napolitano, 2011). This premise that people can think about their thinking, referred to as metacognition, is foundational to the change processes in cognitive-behavioral therapy. Dulmus, Catherine N., et al. Human Behavior in the Social Environment : Theories for Social Work Practice, John Wiley & Sons, Incorporated, 2012. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ncent-ebooks/detail.action?docID=980956. Created from ncent-ebooks on 2020-05-23 15:48:28. 127 128 Human Behavior in the Social Environment However, cognitive-behavioral theory also posits that we do not tend to regularly reflect on our thoughts and thought processes, leaving us largely unaware of problems in our own thinking that may be at least partially contributing to our unease (Mischel, 2007). For brevity’s sake, we are using such terms as thoughts and beliefs. However, the notion of cognition and cognitive activity is quite broad. As Dobson and Dozois (2010) note, a wide range of cognitive constructs and processes have been implicated, including but not limited to thoughts, beliefs, attitudes, assumptions, perceptions, interpretations, attributions, self-statements, scripts, rules for living, values, expectancies, narratives, cognitive distortions, schemas, narratives, and private meanings. In sum, cognitive-behavioral theory proposes that practitioners can play an important role in helping clients with understanding the impact that their thoughts have on their emotions and behaviors, the ways that self and social factors can shape their cognitive activity, and ways that clients can learn how to reflect on and make choices about modifying their thoughts and thought processes to better meet their needs and goals. Historical and Conceptual Origins Copyright © 2012. John Wiley & Sons, Incorporated. All rights reserved. There was a time, not too long ago, when the term cognitive-behavioral therapy was considered an oxymoron . . . . Only a quarter century ago, it was inconceivable to many that there could be anything legitimately called ‘‘mind sciences.’’ Now it is difficult to imagine an adequate approach to psychotherapy that does not appreciate basic contributions from the cognitive sciences. (Mahoney, 2004a, p. 5) This quotation captures the rapid development and dramatic impact of cognitive-behavioral theory and the therapeutic methods it informs. In many respects, cognitive-behavioral theory reflects an ongoing evolution in theorizing, clinical application, and empirical evidence. Definitional boundaries can also be unclear. Some refer to cognitive theory and therapy and others to cognitive-behavioral theory and therapy. Some therapists see themselves predominantly as behaviorists who incorporate findings related to ways that thought, feeling, and action are interrelated. Others see themselves more rooted in the cognitive realm of understanding key processes through which cognitions—particularly errors, distortions, and maladaptive patterns of cognition—give rise to serious problems in living. Still others see themselves as working at an interface that integrates CBT premises with premises or findings from other arenas, such as cognitive science, constructivism, human biology, ecology, psychopharmacology, and substantive factors anchored in respective arenas of practice (e.g., addictions, child and youth development, stress-related problems, problems associated with medical conditions). A strict rendering of the historical origins of cognitive-behavioral theory is made difficult by differing perspectives and a general sense of merging between cognitive and behavioral lines of theorizing relative Dulmus, Catherine N., et al. Human Behavior in the Social Environment : Theories for Social Work Practice, John Wiley & Sons, Incorporated, 2012. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ncent-ebooks/detail.action?docID=980956. Created from ncent-ebooks on 2020-05-23 15:48:28. Cognitive-Behavioral Theory Copyright © 2012. John Wiley & Sons, Incorporated. All rights reserved. to therapeutic techniques (although not without dissent or controversy). Behavior therapy, for example, can be seen as developing in a context that stood in contrast to a medical model of psychopathology and to psychoanalysis as the prevailing therapeutic approach, instead emphasizing pragmatism, symptom relief, use of well-specified methods, and adherence to empirical evidence of underlying theorized principles and therapeutic outcomes. As behavior theories are addressed elsewhere in this volume, we do not review these here. O’Leary and Wilson (1987) identify the following as characteristics typifying behavior therapy (cited in Prochaska & Norcross, 2003, p. 244): Most abnormal behavior is acquired and maintained according to the same principles as normal behavior. • Assessment is ongoing and focuses on currently functioning determinants of behavior. • People are best described by what they think, feel, and do in specific life situations. • Treatment is based on theory and empirical findings. • Practice methods are detailed and replicable. • Treatment is tailored to different problems and people. • Intervention goals and methods are mutually developed and agreed upon with the client. • Specific therapeutic techniques are evaluated as to their effects on specific problems. • Outcomes are evaluated on the basis of observed behavior change, its generalization to real-life settings, and its maintenance over time. We list these background dimensions of behavior therapy as they have carried forward to a considerable extent in the development of cognitive-behavioral theory and therapy. Although effective for a wide range of specific problems, particularly those associated with anxiety, both clinical and empirical experience with behavior therapy began to reflect limitations. Behavior theory underwent dramatic change as a function of the cognitive therapy movement that began in the 1960s and blossomed in subsequent decades. Major early contributors to the cognitive therapy movement include Albert Ellis, Aaron Beck, Michael Mahoney, Joseph Cautela, Donald Meichenbaum, Albert Bandura, and others who introduced cognitively oriented therapies such as rational-emotive therapy, cognitive therapy, self-control and self-regulatory methods, covert sensitization, self-instructional and stress inoculation techniques, coping skills training, problem-solving training, and structural and constructivist perspectives (Foreyt & Goodrick, 2001, and Dobson & Dozois, 2010, provide useful overviews of early major contributors). Models that emphasized conditioning of human behavior by environmental forces began to share space and integrate with models that argued Dulmus, Catherine N., et al. Human Behavior in the Social Environment : Theories for Social Work Practice, John Wiley & Sons, Incorporated, 2012. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ncent-ebooks/detail.action?docID=980956. Created from ncent-ebooks on 2020-05-23 15:48:28. 129 130 Human Behavior in the Social Environment for cognitive mediational processes. These models assert that particular thoughts and cognitive styles shape how stimuli (external events as well as one’s own thoughts and feelings) are experienced and interpreted, which shapes behavioral responding. The shift from behavioral to cognitivebehavioral theory entailed a shift from environmental determinism (that one’s functioning is primarily shaped by the external environment) to reciprocal determinism (that one is an active participant in shaping one’s development as well as being affected by the nature of that environment, in a continual transaction between person and environment). A number of factors have been identified as contributing to the initial theoretical specification of cognitive-behavioral therapy and its rapid ascendance as a preeminent therapeutic approach. Dobson and Dozois (2010) note the following: • • • Copyright © 2012. John Wiley & Sons, Incorporated. All rights reserved. • • • The behavioral perspective was increasingly being seen as insufficient to account for important dimensions of human behavior, yet cognitive extensions were generally not embraced as consistent with behavioral theory. The strongest alternative at the time, the psychodynamic model, had not amassed a persuasive body of evidence documenting its effectiveness. The mediating processes offered by cognitive-behavioral theory articulated a different understanding of mechanisms and, thus, cognitive and affective targets and guidelines for intervention. Basic and applied research on cognitive processes was flourishing, providing empirical support for new and clinically relevant cognitive models. Cognitive-behavioral therapy took hold as an organizing construct and body of work, manifested by major contributors and forums such as new journals that served to establish a focus and platform for exchange about provocative ideas and evolving findings. The growing body of research findings supporting CBT became particularly significant in a context of cost containment and workplace pressures to document use of empirically supported interventions. The following three propositions are central to cognitive behavioral theory: (1) cognitive activity affects behavior; (2) cognitive activity can be monitored and altered; and (3) desired behavior change can be affected through cognitive change. These propositions are found throughout CBT in all its manifestations. However, CBT is not static intervention theory. Theorists and practitioners have continued to develop and refine CBT. Mahoney (1995, 2004b) indicates the major conceptual developments in the cognitive psychotherapies over the past three decades: • The differentiation of rationalist and constructivist approaches to cognition. Although not inherently unrelated, this distinction Dulmus, Catherine N., et al. Human Behavior in the Social Environment : Theories for Social Work Practice, John Wiley & Sons, Incorporated, 2012. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ncent-ebooks/detail.action?docID=980956. Created from ncent-ebooks on 2020-05-23 15:48:28. Cognitive-Behavioral Theory • • • Copyright © 2012. John Wiley & Sons, Incorporated. All rights reserved. • distinguishes a relative emphasis on cognitive content. The rationalist approach emphasizes logic, errors, distortions, and (ir)rationality. Alternatively, the constructivist approach emphasizes a proactive (constructive) view of the nature of cognition that includes a complex system of interchanges among thought, feeling, and action contextualized within a developmental perspective of the self and social systems. The recognition of social, biological, and embodiment issues. Increasingly, factors such as genetics and biological functioning, bodily experiences, physiology, and powerful social forces important to shaping, understanding, and intervening were incorporated into theory. The reappraisal of unconscious processes. There was growing recognition that not all cognition is available to consciousness and that some processes, including automatic thoughts, typically operate without awareness. Such contemporary notions of the unconscious are not the same as those deriving from Freudian theory. However, there is an active effort to illuminate tacit experience and learn its function in psychological health. An increasing focus on self and social systems. Early cognitive approaches tended to be internally focused and relatively inattentive to historical events or to the social and emotional relationship between client and social worker. More recent approaches emphasize complexity of the self and social embeddedness. The reappraisal of emotional and experiential processes. CBT’s early emphasis was on conscious reason as the key vehicle for correcting problems of perception. There is now more focus on cognitive change strategies that emphasize emotion and experiential techniques. Recent decades have witnessed a lessening of sibling rivalries among different psychotherapy theoretical adherents and greater dialogue and conceptual integration among behavioral, cognitive, humanistic, and psychodynamic theorists and practitioners. Accordingly, cognitive psychotherapies have likewise contributed to the psychotherapy integration movement. Research and theorizing have continued with vigor since CBT’s early foundations, to the point that CBT now ranks among the most dominant therapies identified by practitioners, supported by empirical findings, and listed as recommended methods (Cormier et al., in press; Dobson & Dozois, 2010; Prochaska & Norcross, 2010). The combination of theoretical evolution (openness to revisiting and revising theoretical propositions based on new findings), relatively precise documentation of intervention strategies, and a sturdy base of positive outcomes evidence has positioned cognitive-behavioral theory and practice to gain wide support. We now turn to an outline of cognitive-behavioral therapy principles as well as recent theoretical development. Dulmus, Catherine N., et al. Human Behavior in the Social Environment : Theories for Social Work Practice, John Wiley & Sons, Incorporated, 2012. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ncent-ebooks/detail.action?docID=980956. Created from ncent-ebooks on 2020-05-23 15:48:28. 131 132 Human Behavior in the Social Environment Basic Theoretical Principles As discussed earlier, cognitive-behavioral therapy is essentially the application of cognitive-behavioral theory to the individual client’s situation or problem. The specific therapeutic strategies a practitioner may use with coping skills applications, problem-solving skills development, or cognitive restructuring across different clients will vary to fit the change goals. However, there is a common theoretical base that undergirds these different types of cognitive-behavioral therapy. In this section we briefly review several basic theoretical principles of cognitive-behavioral therapy that are critical to understanding the organizing premises used to develop, apply, and adapt cognitive-behavioral interventions. Specifically, we discuss the theoretical principles of the (a) mediational model—how thoughts and beliefs determine emotions and behaviors; (b) information processing—how we human beings manage all the stimuli from our environments and ourselves to meet our needs and goals and how cognition is fundamental to this process; (c) self-regulation—how human beings are active agents with the capacity to alter their thoughts, feelings, behaviors, and environments, and how self regulation can be used as the basis for change in cognitive-behavioral therapy; and (d) the importance of the environment—how a person’s environment, including socioeconomic and sociocultural context, plays a critical role in shaping and activating cognitive content. Copyright © 2012. John Wiley & Sons, Incorporated. All rights reserved. Mediational Model The premise of the mediational model is that stimuli, such as experiences we encounter in life, do not directly determine feelings or lead to behavior but rather go through a filtering process of meaning making, led by the cognitive system that has to attend to and undertake interpretation of the experience and its implications for the person. This interpretative process draws from several levels of thinking, including automatic thoughts, underlying assumptions and rules, and core beliefs. Neenan and Dryden (2004, p. 7) describe negative automatic thoughts as those that involuntarily pop into a person’s mind when experiencing emotional distress; these thoughts are often outside immediate awareness and difficult to turn off. Underlying assumptions (‘‘If I impress others, then I should get ahead in life’’) and rules (‘‘I should not let people down’’) are typically not explicitly articulated and yet tend to be reflective of and to reinforce core beliefs (e.g., ‘‘I am incompetent’’). Core beliefs, which we further address later, take form as schemas that are stored in memory and drawn by relevant life events into information processing, shaping meaning making and thus emotional and physiological states and behavioral responding. The mediational model does not propose a strictly linear process whereby thoughts or beliefs lead to emotions and physiological states, which then dictate behaviors. Rather, there is a dynamic interplay and presumed reciprocal relationships among these elements, such that changing Dulmus, Catherine N., et al. Human Behavior in the Social Environment : Theories for Social Work Practice, John Wiley & Sons, Incorporated, 2012. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ncent-ebooks/detail.action?docID=980956. Created from ncent-ebooks on 2020-05-23 15:48:28. Copyright © 2012. John Wiley & Sons, Incorporated. All rights reserved. Cognitive-Behavioral Theory any one should affect change in the other elements, or at least the overall dynamic. Assuming that an individual has developed negative automatic thoughts, assumptions and rules, and core beliefs that have become deeply established in patterned, habitual responding (e.g., depression, anxiety, poor self-esteem), change in the cognitive architecture that is operating in problematic situations is pivotal. In short, acknowledging dynamic interplay, the mediational model generally posits that emotions and behaviors in a situation flow from the cognitive activity that gets engaged in relating to the experience (e.g., the content of thoughts and beliefs salient in the moment and cognitive processes that carry these in anticipating, interpreting, and reacting, inclusive of thoughts and beliefs about the self, relationships, the world, and the future). To illustrate, two students receive disappointing grades on an assignment in one of their first courses in graduate school. The first student’s cognitive content about the disappointing grade reflects the following beliefs: ‘‘I’m not good at this school stuff and now it’s showing. If I continue to try to get through this, then my incompetence will become more and more apparent. I’m a second-rate student and I’m going to be humiliated in front of my classmates.’’ The second student’s cognitive content about the grade reflects these beliefs: ‘‘Wow! I was not expecting graduate school to be this tough. If I work a lot harder and study more, then I’m going to do better or at least have a better picture of what help I need. I am disappointed about this grade, but I have to keep my focus on my goals, and I know I can do better next time.’’ The cognitive content exhibited by the first graduate student will result in emotions such as embarrassment and anxiety and behaviors of ruminatively worrying about future performance and starting to avoid studying, as that prompts episodes of anxiety, negative self-talk, and a sense that the material is over his head. Alternatively, the cognitive content from the second graduate student will likely result in emotions of resolve and determination and behaviors such as going to the library to study after class. With both students in this example, it is evident that their cognitive content shapes and influences their emotions and behaviors, as well as that the cognitive content mediated the relationship between the life experience of getting a disappointing grade and the subsequent emotions and behaviors. These examples also illustrate ways that behavior contributes to a vicious cycle of emotional distress. People typically act as they think (e.g., if I don’t think I can be successful with something, I’ll likely behave in a manner consistent with this, which serves to sustain my unhappiness with my perceived incompetence). In short, the mediational model posits that problems in one’s behaviors and emotions are indicative of problems in one’s underlying thoughts and thought processes, most likely negative, unhelpful beliefs, assumptions, and automatic response patterns. In first thinking about the idea of the mediational model, it may not be initially clear why emotions play an important role. However, theory and findings show complex relationships; thoughts and beliefs trigger and amplify emotions, emotional content associated with cognition stimulates Dulmus, Catherine N., et al. Human Behavior in the Social Environment : Theories for Social Work Practice, John Wiley & Sons, Incorporated, 2012. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ncent-ebooks/detail.action?docID=980956. Created from ncent-ebooks on 2020-05-23 15:48:28. 133 134 Human Behavior in the Social Environment and alters behavior, and powerful emotions can reinforce thoughts and thought processes, as well as make thoughts seem all the more urgent (Leahy, 2007). Although cognitions are targeted as key inroads to lasting change and behaviors are monitored as indicators of cognitive change and improvement, therapeutic change is predicated on eliciting and managing relevant emotional patterns. Emotions need to be activated in therapeutic work to gain access to emotionally charged cognitions. It is this activated state that allows the social worker to go beyond an abstract, cerebral exchange to actively work with the feeling–thinking linkages and to begin to foster different patterns not only of thinking and behaving, but of feelings (Neenan & Dryden, 2004). Copyright © 2012. John Wiley & Sons, Incorporated. All rights reserved. Information Processing At any given moment of our lives, we human beings are receiving large amounts of information. Often this information is complex, and it originates from multiple sources. To manage this constant exposure to massive amounts of information that come from within us as well as from our environment, we have developed elaborate thinking, feeling, and behavioral processes that enable us to screen out and ignore information that may not be useful or important at a given moment or in a particular situation (A. Beck, 2002). These filtering processes enable us not only to avoid being overwhelmed but also to focus—selectively attending to, interpreting and responding to information that is relevant and that makes is possible for us to progress toward meeting our needs and goals. How exactly is it possible that human beings can manage all the complex information we experience day in and day out and across the development of our life course? Cognitive-behavioral theory maintains that human beings have complex cognitive and affective structures (schemas) that allow us to manage the multiplicity and complexity of internal and external information in efficient and consistent ways. Although these structures generally function with impressive sophistication and utility, this information-processing system has its vulnerabilities. It is, for example, highly conservative and what some have characterized as ‘‘miserly’’—inclined to search in a selfconfirmatory manner for what is familiar, self-relevant, and anticipated, to overlook or resist information that is contradictory, to not see information that is beyond one’s base of experience or imagination, and to extend minimal processing resources unless compelled to do so. Here is an example of how information processing works. Think about the last time you went to a party. You probably had a conversation with a good friend while you were at the party. During your conversation, many other things were probably happening at the party, too. Other people were talking, and there may have been music playing. Let us say that your friend was telling you some important information about promotions at the place you both work and that being promoted is a long-standing career goal of yours. Let us also say that you came to the party hungry and had not made it to the buffet table before you ran into your friend. In addition to all Dulmus, Catherine N., et al. Human Behavior in the Social Environment : Theories for Social Work Practice, John Wiley & Sons, Incorporated, 2012. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ncent-ebooks/detail.action?docID=980956. Created from ncent-ebooks on 2020-05-23 15:48:28. Copyright © 2012. John Wiley & Sons, Incorporated. All rights reserved. Cognitive-Behavioral Theory the activity in the environment, you are also feeling ravenous. For you to attend to your friend’s words (which may give you information to meet a life goal), it was also necessary to screen out all the information and activity going on around you at the party and within you internally. This screening process allowed you to focus on the conversation in such a way that you probably were not even aware that you were filtering out all this other information and activity. In fact, you were probably able to manage all this external and internal information smoothly and fairly easily and were also able to engage in this important conversation. Though shortly after this conversation ended, you probably began searching for the buffet table! The task of attending to a conversation at a party is a fairly simple example of information processing. In fact, information processing occurs in an intricate, interconnected, and interdependent system of cognitiveaffective-behavioral structures (A. Beck, 1996). These structures take in information, assign meaning, and evoke corresponding emotions, which all lead to behavioral responses in reaction to the information. Keep in mind that information processing occurs during every activity and behavior, from driving a car to playing basketball with friends to giving a presentation at work. Consider, too, ongoing activities and behaviors that occur over time, such as planning and taking a vacation, developing and completing a project at work, and parenting a child, just to name a few examples. Information processing is an operative part of every waking moment, sometimes functioning in a fairly automatic way (walking down the street, doing the laundry), sometimes in a more deliberate way that involves more explicit attention (hearing a child scream as one is walking down the street, coming across contraband material in your son’s pants pocket as you do the wash). Human beings have patterned and stable cognitive-affective information processes for all aspects of our lives and our personalities. On the one hand, the stability and consistency of these information-processing structures is adaptive, even essential, and facilitates human functioning in an efficient manner, conserving energy for needed times (Berlin, 2002; Macy, 2006). Consider the example of driving a car. Imagine if every time you drove your car you had to consciously think through every step and decision—all the mechanics of driving, from getting into the car to turning the steering wheel, as well as the vast attentional energy required to purposely examine every bit of visual, auditory, and tactile information one encounters along the way. It would take a long time to get to your destination, would be exhausting and stressful (given that one has to sustain a continuous level of high alert and highly active processing trivial environmental information), and might even increase your risk of an accident given that attentional focus is so diffuse and taxing, reaction time to truly significant information is impaired. However, the stability and consistency of cognitive-affective structures can also cause problems. To the extent that an individual has, for example, schematic structures underlying core beliefs about the self and the world containing information or ideas that are dominantly negative, Dulmus, Catherine N., et al. Human Behavior in the Social Environment : Theories for Social Work Practice, John Wiley & Sons, Incorporated, 2012. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ncent-ebooks/detail.action?docID=980956. Created from ncent-ebooks on 2020-05-23 15:48:28. 135 136 Human Behavior in the Social Environment that person’s expectancies, interpretations, feelings, and responses are going to be infused and directed by this dominantly negative content in a system that will resist challenge or change, as do all well-developed cognitive-affective structures (Nurius, 2008). These difficulties in thinking, feeling, and behaving will pose problems for the person in terms of getting needs met and pursuing life goals. Although the person may be fully aware that needs and goals are not being successfully met, the person may not understand why the problems exist because the underlying cognitiveaffective-behavioral processes, which contain unhelpful information, are so efficient and automatic that the person is not aware of the problematic information (Mischel, 2007). Erroneous cognitive-affective structures tend to be self-perpetuating, as the act of processing information through a specific structure serves to reinforce the underlying content and the relative ease or accessibility of that structure for future processing. On the one hand, information processing that draws on predominantly healthy and adaptive cognitive-affective structures is key to human beings’ capacity to survive and thrive in a complex world. On the other hand, information processing that draws on predominantly unhealthy and maladaptive cognitive-affective structures can cause serious problems that impair a person’s capacity to survive and thrive. Copyright © 2012. John Wiley & Sons, Incorporated. All rights reserved. Self-Regulation Fortunately, as discussed earlier, our ability to think about our thinking (metacognition) gives us the capacity to become aware of our cognitive content and processes. With increased awareness of these generally automatic processes, we can then alter and replace problematic, inaccurate, and unhelpful beliefs and thoughts that underlie our problems in feeling and functioning. Although cognitive structures must be resistant to change to provide coherence and stability, they can be altered, modified, and replaced (J. Beck, 2011). By directing attention to and modifying problematic thoughts and underlying schemas that thwart our efforts to meet our needs and pursue our goals, we can also change and direct emotions and behaviors to better meet our needs and goals (Dobson & Dozois, 2010). As Berlin (2002) emphasizes, we humans are active agents in our own lives in the way we seek out, select, and manage information and experiences. Although we are constantly and consistently showered with information, we are not sponges simply soaking up information. We can also use our metacognitive capacity to think about our thinking to better direct our thoughts, feelings, and behaviors in ways that help us meet our needs and goals. This capacity to observe and reflect on our thinking, as well as our ability to direct our thoughts, feelings, and behaviors in ways that help us best meet our needs and goals, is termed self-regulation and is another basic principle of cognitive-behavioral theory. Cognitive-behavioral theory views the person as an active agent in the construction of perceived reality and the social and psychological interchanges both among and within individuals. Beyond reacting to the world, Dulmus, Catherine N., et al. Human Behavior in the Social Environment : Theories for Social Work Practice, John Wiley & Sons, Incorporated, 2012. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ncent-ebooks/detail.action?docID=980956. Created from ncent-ebooks on 2020-05-23 15:48:28. Copyright © 2012. John Wiley & Sons, Incorporated. All rights reserved. Cognitive-Behavioral Theory we also dynamically search for, choose, and use information to construct our realities and make meaning in our lives, including our understandings of our self, our relationships, the world, and our future. Although much of the way that people are exercising their agency or influence in this regard resides beyond common awareness, cognitive-behavioral theory views our cognitive-affective-behavioral patterns as knowable, accessible, and modifiable. This theoretical premise is the cornerstone of cognitivebehavioral interventions, be they cognitive restructuring, coping skills training, emotional regulation, or other specific strategies. Recall the example of the graduate student who received the unsatisfactory grade and thought to herself, ‘‘I am disappointed about this grade, but I can do better next time,’’ and then headed off to the library; this is an illustration of self-regulation. Let’s assume that both students had the abstract knowledge that academic performance can generally be improved through study, perseverance, and tutoring. One student had a core belief consistent with herself as being able to accomplish this connection, whereas the other did not. Clearly, the self-regulatory task for the student with a negative core belief is considerably more difficult than for the other student. Self-regulation for the former student would involve observing and reflecting on cognitive patterns (negative automatic thoughts, assumptions and rules, and core beliefs about her academic competence), feeling states (embarrassment, anxiety, disappointment), and behaviors (avoidance strategies) that are contributing to her problems and then undertaking activities to interrupt these patterns and work to invoke and reinforce new patterns. A number of specific strategies could be used to assist with this effort. However, central to the effort will be the incremental progress toward challenging the negative core belief and reinforcing a new positive belief structure and information-processing habits regarding her academic competence, the possibility of achieving success, and the ‘‘how-tos’’ and ‘‘what-ifs’’ for self-regulating through challenges and backslides along the way. Self-regulation often involves not only deliberate, explicit focus on changing beliefs and thought patterns, but also explicitly working to manage one’s physiology (e.g., bodily reactions associated with anxiety, embarrassment), coping patterns, and mood. What is noteworthy about the example of the positive belief student is how she automatically engaged in positive, helpful thinking patterns that supported behaviors that are adaptive for success in her academic goals. Part of what makes self-regulation difficult is this automaticity; both adaptive and problematic patterns are typically implicit and unscrutinized (Dunkley, Blankstein, & Segal, 2010). Experientially, it feels like ‘‘what is,’’ a kind of truth or reality (‘‘I’m just not good at this—never have been, never will be’’). The theoretical premises underlying self-regulation essentially frame the client as a personal scientist. Embedded within an overarching social learning and psychoeducational framework, selfregulation entails an assumed ability, with assistance, for clients to (a) gain awareness of their heretofore unobserved and automatic patterns, (b) test the validity of their problematic beliefs and thoughts, and (c) collaborate Dulmus, Catherine N., et al. Human Behavior in the Social Environment : Theories for Social Work Practice, John Wiley & Sons, Incorporated, 2012. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ncent-ebooks/detail.action?docID=980956. Created from ncent-ebooks on 2020-05-23 15:48:28. 137 138 Human Behavior in the Social Environment with the counselor to modify these patterns (Neenan & Dryden, 2004). Although the process of self-regulation requires energy and overcoming an inherently conservative cognitive-affective-behavioral system, humans are also inherently motivated to understand, gain meaning, and be agentic in their own functioning—assets to the process of self-regulatory change. How this capacity can be used for therapeutic purposes is discussed in greater detail later in the chapter. Copyright © 2012. John Wiley & Sons, Incorporated. All rights reserved. The Importance of Environment Social work professionals frequently work from a biopsychosocial perspective and often use frameworks that emphasize the importance of the environment, such as person-in-environment perspective, the metatheory of systems, and the ecological framework. The emphasis on the individual client’s interactions with various aspects of his or her environment (e.g., family, neighborhood, community, government) is critical for social work professionals because we conceptualize problems in human functioning in terms of disruptions and problems in our clients’ environment as much as we conceptualize problems in human functioning as stemming from within the person. Because of this emphasis, social workers may wonder to what extent cognitive-behavioral theory is useful for social work practice. We have noted that cognitive-behavioral theory sees the individual as deeply and continuously embedded within complex social environments, with functioning a product of reciprocal relationships between persons and their environments. Nonetheless, we have emphasized (as does much of the literature) the cognitive, affective, and behavioral processes that happen within the individual. It would be a mistake, however, to assume that cognitivebehavioral theory conceptualizes problems in human functioning as lying entirely within the individual. In fact, person-in-environment interactions are essential in how cognitive-behavioral theory understands problems in human functioning, as well as in how social workers use cognitivebehavioral interventions to address a client’s problems. Neenan and Dryden (2004) emphasize a focus on correcting the combination of psychological and situational factors that are contributing to an individual’s distress and working collaboratively with the client to understand how objectively unpleasant situations are experienced as well as how these may be exacerbated by how the client appraises or makes meaning of these situations in ways that impair his or her ability to cope with them. Let us consider two ways in which a client’s environmental milieu, which includes the client’s socioeconomic and sociocultural context, come into play in a cognitive-behavioral theory perspective (Macy, 2006; Nurius, 2008). First, people’s environment will inevitably play a considerable role in forming and presenting the opportunities, experiences, and information to which they have access. As a result, the characteristics of their environment will likely shape the thoughts, beliefs, and ideas that form the basis of people’s information processing and capacity to self-regulate their Dulmus, Catherine N., et al. Human Behavior in the Social Environment : Theories for Social Work Practice, John Wiley & Sons, Incorporated, 2012. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ncent-ebooks/detail.action?docID=980956. Created from ncent-ebooks on 2020-05-23 15:48:28. Copyright © 2012. John Wiley & Sons, Incorporated. All rights reserved. Cognitive-Behavioral Theory thinking, feeling, and behaving. Patterned ways of responding typically derive from formative experiences with the social environment. For example, a person who lives on the flat plains may never have the experience of downhill skiing because the geographic environment limits the person’s opportunities to have this experience. Without mountains and considerable snow, a person may never learn to ski and thus will never develop cognitive-affective-behavioral processes for the activity of skiing. However, if this person has economic resources and can travel, then he or she may go to a snowy, mountainous geographical area on vacation, take skiing lessons, and subsequently become proficient at this activity. Again, the person’s environmental realities—in this case, the fact that the person has economic resources—have provided the opportunity for the development of cognitive-affective-behavioral processes for the activity of skiing. This is a fairly benign example of how a person’s environmental context can shape cognitive-affective-behavioral processes. However, given the social work profession’s emphasis on social change and social justice, the reader may wish to consider how deleterious aspects of a person’s environment, for example, poverty, racism, and neighborhood crime, also impact a person’s cognitive, affective, and behavioral functioning. As Berlin (2002) emphasizes, the opportunities to which human beings have access may limit their capacity to create alternative ways of seeing themselves, relationships, future, and the world. Second, established cognitive-affective-behavioral patterns are often activated by the environmental context. A person’s internal experience (thoughts, feelings, bodily sensations) also activate relevant cognitiveaffective-behavioral systems. Think of your own thinking, feeling, and behaving processes when you find yourself hungry or sleepy. In the flow of everyday life, we are constantly experiencing thoughts and beliefs being activated and made momentarily salient and influential by the experiences, events, or situations we are encountering. As an example, think back to our two graduate students who both received disappointing grades on their assignments. Let’s consider the student who began to anxiously ruminate, leading to avoidance coping behaviors. Let’s further imagine that this student found out right before class that his partner of 1 year decided to break up with him. As a result, of receiving these two pieces of bad news so close together, which are examples of external events, our student is feeling particularly discouraged, sad, and hopeless. But let’s also imagine that on the way to a student bar with the intent to drown his sorrows a bit, the student runs into a good friend. This friend joins him for a beer but also provides a listening ear and a clear-eyed shoulder to cry on. As a result of this friend’s help and support, our graduate student feels more hopeful and heartened. The next day, he joins the other graduate student for an all-day study session in the library. This illustration provides multiple examples—the assignment grade, the problem relationship, the supportive friend—of how the current environmental context can activate relevant cognitive content in a way that shapes a person’s thinking, feeling, and behaving. Dulmus, Catherine N., et al. Human Behavior in the Social Environment : Theories for Social Work Practice, John Wiley & Sons, Incorporated, 2012. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ncent-ebooks/detail.action?docID=980956. Created from ncent-ebooks on 2020-05-23 15:48:28. 139 140 Human Behavior in the Social Environment Clearly, the kinds of problems and contexts with which many social work clients are struggling carry many levels of stress, hurt, inequity, and impoverishment. No one change or support approach will be a panacea, and cognitive-behavioral theory lays no claim to being a vehicle to correct environmental oppression and ills. Rather, this theory illuminates the ways that individuals can gain awareness of both the stresses and resources of their environments as well as the ways they are engaging with that environment to exert influence in the best interest of their own needs, goals, and well-being. To accomplish this, practitioners who use cognitive-behavioral therapy, guided by an understanding of their client’s environmental context, including developmental and cultural history, family and friend relationships, economic realities, and environmental factors, may well pair CBT with interventions targeted at external resources or problem contributors. Copyright © 2012. John Wiley & Sons, Incorporated. All rights reserved. Advanced Theoretical Principles Although the theoretical principles we selected as basic apply across the range of cognitive-behavioral intervention strategies, other theoretical constructs will be pertinent when more in-depth cognitive challenges and restructuring are involved. These may pertain, for example, to work with individuals who are suffering from serious depression or chronic maladaptive behaviors and deeply patterned interpersonal functioning problems. It is beyond the scope of this chapter to detail applications of CBT methods or to elaborate in depth. We select core beliefs and cognitive errors as two features of cognitive-behavioral theory that build on and go beyond underlying basic principles. Additional resources for recent summaries of advanced cognitive-behavioral theory and therapeutic techniques, with emphasis on schemas, the role of emotions, and complex cases include A. T. Beck (2005), Leahy et al. (2011), Persons (2008); Safran, EubanksCarter, and Muran (2010), and Young, Rych, Weinberger, and Beck (2008). Core Beliefs Earlier we introduced the construct of core beliefs as the deeper cognitive structures (typically assumed to be stored in memory as schemas and situationally activated) that carry the content—positive or negative—of what individuals believe to be fundamentally true about themselves and their world. In applying cognitive-behavioral therapy to human problems at a foundational level, the distinctions among different types of cognitions are not always critical. However, at an advanced level of understanding, knowing the distinctions among cognitions will help to refine and advance a clinician’s assessment and intervention. Core beliefs, also called schemas, are the underpinnings of information processing because they are the memory structures that store descriptive information, beliefs, judgments, and ideas about the self, relationships, the world, and the future (DeRubis et al., 2010; Martin & Young, 2010). Core beliefs take time and repeated use to become well-elaborated Dulmus, Catherine N., et al. Human Behavior in the Social Environment : Theories for Social Work Practice, John Wiley & Sons, Incorporated, 2012. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ncent-ebooks/detail.action?docID=980956. Created from ncent-ebooks on 2020-05-23 15:48:28. Copyright © 2012. John Wiley & Sons, Incorporated. All rights reserved. Cognitive-Behavioral Theory and overgeneralized. Once well-developed, they tend to be experienced as tacit truths and are stable, complex, and resistant to change. Core beliefs are storage repositories, but they are by no means static. These cognitive schemas are theorized to be the main drivers directing what we attend to, how we make interpretations, what feeling states are evoked, and what behaviors we are then predisposed to. In relation to information processing, the resilience of core beliefs is often adaptive and helpful because they allow us to process and to make sense of new information in efficient and consistent ways. However, when core beliefs contain unhelpful, inaccurate, or maladaptive information, they can cause considerable problems in thinking, feeling, and behaving. Core beliefs generally comprise foundational information about the self, relationships, the world, and the future and are theorized to have had their initial formation in childhood and early adolescence. Cognitivebehavioral theory hypothesizes that formative life experiences develop and reinforce these central cognition structures because they were functional and useful during these key developmental periods. With repeated application colored by the conservative, self-confirmatory bias of the cognitive system, these schemas were maintained and strengthened, being used to interpret and assign meaning to new experiences that further elaborate them. To identify a client’s fundamental core beliefs, which may hold problematic information for the client’s current life, a comprehensive developmental assessment can provide information and insight to the contexts from which a client’s core beliefs emerged and what functions they served at the time. Because core beliefs so powerfully shape a person’s thoughts, emotions, and behaviors, they are essential and critical targets for deep-level change from a cognitive-behavioral theory perspective (J. Beck, 1995; DeRubis et al., 2010). In fact, many who do research on and write about cognitive-behavioral theory hypothesize that lasting cognitive, affective, and behavioral change requires an alteration in problematic core beliefs. There are several challenges to altering core beliefs. One is the process of helping clients become aware of these underlying cognitive processes that contain negative, maladaptive information. Because these cognitive structures have become so embedded in a person’s sense of identity, life philosophy, understanding of reality, and patterned way of being in the world, the intervention tasks of identifying, challenging, and disrupting habitual thought processes and then developing and reinforcing competing, more adaptive core beliefs require considerable skill and sustained commitment by client and counselor alike. However, core beliefs can be altered in a way that is helps clients to better address their needs and goals (Dowd, 2002; Leahy, 2003a). Cognitive Errors In our discussion of the mediational model we described how unhelpful thoughts and beliefs contribute to problems in feeling, behaving, and functioning. Some of this stems from maladaptive cognitive content, such Dulmus, Catherine N., et al. Human Behavior in the Social Environment : Theories for Social Work Practice, John Wiley & Sons, Incorporated, 2012. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ncent-ebooks/detail.action?docID=980956. Created from ncent-ebooks on 2020-05-23 15:48:28. 141 Copyright © 2012. John Wiley & Sons, Incorporated. All rights reserved. 142 Human Behavior in the Social Environment as negative core beliefs. Some stems from maladaptive patterns of thinking or cognitive processes. Cognitive errors are one such set of problematic patterns of thinking stipulated in cognitive-behavioral theory. Cognitive errors can occur at various levels of thought, including core beliefs as well as surface thoughts. Thus, cognitive errors are found both within a person’s fundamental beliefs about the self, relationships, the world, and the future, as well as in spontaneous, transitory thoughts. In some respects, the term cognitive error is a misnomer to the extent that it conveys a notion of some absolute reality or truth against which an individual’s perceptions are gauged for accuracy. Consistent with the educational, learning approach of cognitive-behavioral therapy, the term ‘‘error’’ conveys a pattern of cognitive responding that can be reflected on as to its helpfulness to the person and modified to bring patterns of responding more in alignment with the individual’s comfort and goals. Within the general concept of cognitive errors there are several types of cognitive errors that have been broadly observed in clinical and empirical work, particularly those associated with emotional states. DeRubis et al. (2010) review common examples of cognitive error. Magnifying problems reflects the tendency to make one small event or problem bigger than it actually is or might fair-mindedly be viewed to be. For example, a person who is planning an once-in-a-lifetime, dream vacation and who runs into some problems as she tries to reserve a hotel room may think to herself, ‘‘The hotel I really wanted to stay at on my vacation is overbooked. This is awful! I might as well not go on the trip at all then, because it will ruin my whole vacation if I cannot stay at that hotel!’’ It is unlikely that this is the only suitable hotel in which our vacation planner can stay (although this would need to be explored). She may begin thinking about the entire vacation, not just the overbooked hotel, in a negative way, which in turn may lead to negative feelings, including disappointment, about her vacation plans. The fact that her thinking is focused on this one apparently minor factor is likely magnifying the problem in a way that colors her entire view of what was once her dream vacation. We all magnify (or minimize) at times. It becomes a problem, though, when there are repeated patterns—particularly when the individual is unaware of the polar extremes that are coloring her or his interpretations and feelings, patterns that lead to ongoing unhappiness and imbalance. Another cognitive error, jumping to conclusions, reflects the tendency to come to a conclusion before gathering all the information, particularly conclusions that reinforce a negative existing belief. For example, a recent high school graduate who is looking for a job may think to himself, ‘‘It’s been a day, and I have not heard back from my job interviewer, so I must not have gotten the job.’’ Likely this thought will lead to other negative thoughts (e.g., ‘‘Why do I bother looking? No one will want to hire me’’) and negative feelings, such as frustration and despondency. These negative thoughts and feelings may in turn lead to unhelpful actions and behaviors (e.g., deciding to watch TV all day instead of sending follow-up e-mails to Dulmus, Catherine N., et al. Human Behavior in the Social Environment : Theories for Social Work Practice, John Wiley & Sons, Incorporated, 2012. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ncent-ebooks/detail.action?docID=980956. Created from ncent-ebooks on 2020-05-23 15:48:28. Copyright © 2012. John Wiley & Sons, Incorporated. All rights reserved. Cognitive-Behavioral Theory places where he sent his resume), which may also cause difficulty in his search for a job. Discounting positives refers to the propensity to concentrate on negative experiences or aspects of a situation rather than the positive experiences or aspects. For example, a college instructor received many positive reviews from students about his teaching, but he can only focus on the few negative comments, possibly dismissing the positives as naive perspectives whereas the negatives show ‘‘the real truth’’ about his teaching. Overgeneralizations reflect the inclination to view one negative experience as the rule (e.g., ‘‘I asked a guy out once, but he said no. So I will never ask another guy out because they all will say no to me’’); this is likely accompanied by affective states like embarrassment and a sense of hopelessness about this changing. Mind reading takes form through believing we know what other people are thinking, believing, and feeling, irrespective of whether we have any information in this regard. A person who is engaging in this cognitive error may think to herself, ‘‘My supervisor did not speak to me in the hall when she passed me! That’s not like her. I bet she is thinking of including me in the next round of layoffs and does not want to speak me.’’ There could be many reasons why this person’s supervisor did not stop to say hello. She may have been busy or distracted. However, a person who is engaged in one cognitive error may also tend to disregard any information that disconfirms the unhelpful thought and instead focus only on thoughts and feelings that support his or her unhelpful belief. Unfortunately, as the mediational model posits, cognitive errors generally lead to difficult, negative emotions, as well as unhelpful and maladaptive actions and behaviors. Dobson and Dozois (2010) list other forms of cognitive error: All-ornothing thinking segments experiences into two, often extreme or reductionistic, categories (e.g., flawless or defective). In fortune-telling, one’s beliefs and/or feelings about the future are how things will be, discounting or ignoring other possibilities. Emotional reasoning is perceiving things to be true on the basis of one’s feelings; if something ‘‘feels true’’ (e.g., is consistent with how one is feeling about oneself or others), this is evidence of its truth. Clients who make ‘‘should’’ statements blur duty and desire; they frame events in evaluative ‘‘should’’ terms (should have done; not done) when ‘‘would like to have done/not done’’ is more accurate. Labeling is applying a label to describe a behavior, then ascribing other meanings that the label carries (e.g., ‘‘I’m a ‘bad mother’ for losing my patience with my child. Bad mothers are negligent, unkind, and undeserving of their children.’’). Inappropriate blaming is a restrictive view of events that funnels into an overly narrow blaming stance (e.g., using hindsight to judge what should have been done even if that could not have been known at the time; discounting others’ contributions to a problem or mitigating factors). As you are reading about these different types of cognitive errors, it may occur to you that we human beings frequently engage in many of these types of problematic thinking and unhelpful beliefs on a regular Dulmus, Catherine N., et al. Human Behavior in the Social Environment : Theories for Social Work Practice, John Wiley & Sons, Incorporated, 2012. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ncent-ebooks/detail.action?docID=980956. Created from ncent-ebooks on 2020-05-23 15:48:28. 143 144 Human Behavior in the Social Environment basis. In fact, from a cognitive-behavioral theory perspective, all human beings are prone to thinking in ways that do not always help us to meet our needs and to reach our goals and to think in ways that can cause problems for us. Fortunately, as we emphasized in our discussion of the basic theoretical principles of cognitive-behavioral theory, human beings can also think about their thinking and change their thoughts, beliefs, and ways of thinking. As a result of this capacity, we are not necessarily stuck with our unhelpful, problematic, and maladaptive thoughts and beliefs. As human beings use their capacity to reflect on problems in their thinking, they can also change their thoughts and beliefs to be helpful and adaptive. In our discussion of the relevance of cognitive-behavioral theory for social work practice, we discuss how practitioners can use specific cognitivebehavioral therapy techniques to help clients change their thinking to support adaptive ways of thinking, feeling, and behaving. Recent Theoretical Developments Copyright © 2012. John Wiley & Sons, Incorporated. All rights reserved. Over the past decade there have been several substantial developments. Some have characterized these as third-generation or third-order developments, following first-generation traditional behavioral therapy and second-generation behavioral therapies that integrated cognitive science (i.e., cognitive-behavioral therapy). These new directions embrace concepts such as acceptance, dialectics, spirituality, relationship, and mindfulness (Arch & Craske, 2009; Hayes, Follette, & Linehan, 2004). This third generation of therapy has been defined in the following way (Hayes, 2004b, cited in Hayes, 2004a, p. 6): Grounded in an empirical, principle-focused approach, the third wave of behavioral and cognitive therapy is particularly sensitive to context and functions of the psychological phenomena, not just their form, and, thus tends to emphasize contextual and experiential change strategies in addition to more direct and didactic ones. These treatments tend to see the construction of broad, flexible, and effective repertoires over an elimination approach to narrowly defined problems, and to emphasize the relevance of the issues they examine for clinicians as well as clients. The third wave reformulates and resynthesizes previous generations of behavioral and cognitive therapy and carries them forward into questions, issues, and domains previously addressed primarily by other traditions, in hopes of improving both understanding and outcomes. Orsillo, Roemer, Lerner, and Tull (2004) provide an overview of developments in and beyond traditional CBT, particularly related to anxiety disorders. They acknowledge the important evidence base supporting CBT (albeit with limitations) as well as concerns that most individuals receiving community-based psychotherapy do not receive empirically supported forms of intervention. Modern learning theory has pointed to the importance of personal meaning both in how problematic symptoms (such as anxiety) arise as well as methods to interrupt dysfunctional patterns of cognitive and emotional responding, such as panic. Personal meaning Dulmus, Catherine N., et al. Human Behavior in the Social Environment : Theories for Social Work Practice, John Wiley & Sons, Incorporated, 2012. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ncent-ebooks/detail.action?docID=980956. Created from ncent-ebooks on 2020-05-23 15:48:28. Copyright © 2012. John Wiley & Sons, Incorporated. All rights reserved. Cognitive-Behavioral Theory points to the variability in how similar events can hold very different connotations and significance for different people. This strain of theorizing points to ways to build on techniques such as exposure therapy—for example, through assessing meaning and context in designing treatment—to better incorporate different emotionally charged meanings and life conditions that may otherwise impede therapeutic efforts. This growing attention to variation in personal meaning may provide important inroads for appreciating cultural diversity in underlying beliefs, values, expectations, and spiritual or existential philosophy as well as variation in how predictable or controllable any given event may be and the perceived implications of disturbing events for one’s fundamental identity and worth. Acceptance-based methods are a new wave of CBT-derived clinical approaches that explicitly address treatment impediments, such as clients’ fear and avoidance of internal experiences. These emerging methods address a critical clinical dilemma. Avoidance of deeply distressing thoughts and feelings (such as those associated with trauma) is associated with later increased distress and symptom severity (Gilboa-Schechtman & Foa, 2001) and may incline some clients to avoid or refuse traditional CBT interventions and/or increase their risk of dropping out of treatment. Acceptance and commitment therapy, one such third-wave outgrowth, targets experiential avoidance and increasing acceptance. Experiential acceptance is defined as ‘‘willingness to experience internal events, such as thoughts, feelings, memories, and physiological reactions, in order to participate in experiences that are deemed important and meaningful’’ (Orsillo et al., 2004, p. 76). Similar emphasis on experiential acceptance is also evident in dialectical behavior therapy (Dimeff & Koerner, 2007; Linehan, 1993), integrative behavioral couple therapy (Christensen et al., 2004), and mindfulness-based cognitive therapy (Segal, Williams, & Teasdale, 2002) and mindfulness-based stress reduction (Roth & Calle-Mesa, 2006). Acceptance-based approaches work to assist individuals to be able to tolerate exposure to thoughts and feelings that are highly aversive and uncomfortable to them, moving to the capacity to observe both external and internal stimuli with an openness to acceptance rather than attempts to judge, flee, avoid, or change them (Segal et al., 2002). Although acceptance-based methods are similar in several ways to CBT methods, the former emphasizes core values and quality of life, commitment to actions likely to help actualize these values and goals, metacognitive awareness that helps one observe distressing internal events more neutrally, a shift from changing thought content to changing one’s relationship to one’s own internal responding, and concern that attempts to directly control internal responses will more likely foster problem maintenance than resolution (Orsillo et al., 2004). Mindfulness practice is gaining supportive evidence (Baer, 2006; Bowen, Chawla, & Marlatt, 2011; Shapiro & Carlson, 2009) as an acceptance technique for augmenting tolerance of one’s negative affect and cognition, fostering changes in attitude about one’s internal events, ability to self-monitor and manage thoughts and feelings that are highly aversive, and facilitating relaxation Dulmus, Catherine N., et al. Human Behavior in the Social Environment : Theories for Social Work Practice, John Wiley & Sons, Incorporated, 2012. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ncent-ebooks/detail.action?docID=980956. Created from ncent-ebooks on 2020-05-23 15:48:28. 145 146 Human Behavior in the Social Environment (Orsillo et al., 2004). However, evidence is as yet preliminary. How these techniques function is not yet clearly established, nor has there been sufficient comparative analysis (e.g., to discern whether acceptance-based approaches significantly extend the effectiveness of CBT theories and interventions). Nonetheless, theoretical and clinical work is under way (e.g., Roemer & Orsillo, 2009) to better specify how this spiritual tradition fits into current theory and clinical methods. Relevance to Social Work Practice Copyright © 2012. John Wiley & Sons, Incorporated. All rights reserved. Consistent with the mediational model, a core emphasis in cognitivebehavioral interventions is on changing cognitions to produce and sustain change in emotional distress and maladaptive behavior patterns. Frequently, these therapies are applied in a fairly specific problem-focused manner within relatively limited time frames (although more in-depth schema-based change involves more extensive therapeutic effort). In addition, these therapies aim for well-delineated goals as outcomes, typically including behavioral evidence. For example, a person is behaviorally functioning in a manner more in line with change goals such as less depressed, more adaptive coping, more effective problem solving. As a result of these emphases, cognitive-behavioral therapies are particularly relevant for today’s practice in many areas of human service and across a variety of problems. In addition to being required to use evidence-based practices, many human service providers are also struggling with diminished resources and frequently being asked to serve more people in efficient ways. In this section we illustrate specific ways in which cognitive-behavioral theories and therapies can be used in social work practice. Uses in Assessment Because problematic thoughts sustain a client’s intrapersonal and interpersonal problems, practitioners are applying CBT work to identify relevant unhelpful and maladaptive cognitions, both surface thoughts and core beliefs (DeRubis et al., 2010). However, as discussed earlier, cognitive content and processes are often not realized or easily recognized by the client. This is particularly the case for thoughts that are part of clients’ core beliefs. That is, clients may be more aware of their negative automatic thoughts, but they are less likely aware of the core beliefs that underlie these automatic thoughts and thought processes. For example, few clients will say to a practitioner something like, ‘‘I have a view of myself, my relationships, and the world that is fundamentally negative, and it is causing me serious problems.’’ Rather, in a first meeting with a practitioner, clients are more likely to describe a presenting problem in terms of their difficult and negative feelings or in terms of the interpersonal problems they are experiencing (Macy, 2006). As a result, practitioners using cognitive-behavioral therapy need to use strategies to identify the Dulmus, Catherine N., et al. Human Behavior in the Social Environment : Theories for Social Work Practice, John Wiley & Sons, Incorporated, 2012. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ncent-ebooks/detail.action?docID=980956. Created from ncent-ebooks on 2020-05-23 15:48:28. Cognitive-Behavioral Theory Copyright © 2012. John Wiley & Sons, Incorporated. All rights reserved. cognitive activity that is most related to the client’s presenting problem. We present several of these strategies. Strategies for Identifying Cognitive Content Cognitive-behavioral therapy is predicated on the educational premise that the more clients understand the basic logic behind the model, the better positioned they will be to incorporate these strategies into their own repertoire. This will give clients the ability to step outside patterns that are troubling to them to assess the ‘‘how come’’ questions, consider their options, and gain skills that they can apply to this and future problems in functioning. Thus, many cognitive-behavioral assessment strategies can be used both in meetings between practitioner and client as well as outside formal sessions. Most assessment strategies can also be used in a variety of settings: in a practitioner’s office, during a home visit, or in a situation or setting that is part of the client’s presenting problem (e.g., in a work setting if the client is having difficulty there). These strategies may need to be appropriately adapted to different settings and clients. One cognitive assessment strategy entails asking a client to think aloud during a task, situation, or role-play (Dunkley et al., 2010). In this strategy, the client is encouraged to report and describe any thought, idea, or belief in order to identify cognitive content that is related to the presenting problem or difficulty. To facilitate activation of relevant cognitive structures, the client is coached to enact this exercise in a task, situation, or context that is related to the presenting problem or is causing the client distress. For example, if a client presents with problems in his or her role as a parent, a practitioner can have the client role-play an activity that is related to this problem (e.g., helping the child with homework). During the role-play, the client will report thoughts, beliefs, and ideas that generally happen when engaged in this activity. The practitioner may need to prompt the client to report and describe these ideas and thoughts, and the practitioner may want to record the think-aloud ideas in writing to obtain all the information elicited by the client. This kind of technique generally begins with negative automatic thoughts, progressing to underlying assumptions and rules, and, if needed, identifying negative core beliefs (see Leahy, 2003a; Neenan & Dryden, 2004, for elaboration). Another broadly applied cognitive assessment strategy is selfmonitoring (Cormier et al., in press; DeRubis et al., 2010). One type of self-monitoring is the thought record log, in which the client is asked to record ideas, thoughts, and beliefs that occur during a specific activity, in a certain situation, or over a certain period of time (J. Beck, 2011). Or the practitioner can have the client record thoughts in relation to a specific activity or time. For example, a client who has a presenting problem of distressing anxiety during public speaking and who also must frequently speak publicly might be asked to record his thoughts while preparing to speak and then immediately after speaking. Information from this client’s thought record log will provide helpful information to the practitioner who is conceptualizing the client’s case. Dulmus, Catherine N., et al. Human Behavior in the Social Environment : Theories for Social Work Practice, John Wiley & Sons, Incorporated, 2012. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ncent-ebooks/detail.action?docID=980956. Created from ncent-ebooks on 2020-05-23 15:48:28. 147 Copyright © 2012. John Wiley & Sons, Incorporated. All rights reserved. 148 Human Behavior in the Social Environment Another example of self-monitoring is thought listing (Dunkley et al., 2010). In this exercise, the client is asked to list any thoughts he or she may have had during an experience related to the presenting problem or during a distressing situation, either through enactment methods in a formal helping session or in the context of relevant experiences outside of formal sessions. For example, a practitioner may ask a client who is having difficulty at work to take a few minutes to record all her thoughts about work the next time she is feeling particularly anxious or distressed there, bringing these notes in for examination with the social worker. Information about relevant cognitive content gathered outside of client-worker meetings can be particularly informative, because cognition patterns of responding are typically activated by particular situations, experiences, contexts, activities, and mood states. Visualization, guided imagery, role-play, and other invoking strategies can often be significantly supplemented by monitoring in relevant situations as these emerge. This reflects another dimension of cognitive-behavioral theory highly relevant to social work: careful attention to patterned interchanges between environmental factors and cognitive-affective-behavioral configurations related to the client’s presenting problem. As discussed earlier, cognitions do not occur without a context or stimulus; both are formative in a client’s history and operative in clients’ present-day habits and conditions. Cognitivebehavioral theory is influenced by social psychological findings regarding the ongoing self-social interface (Nurius, 1991, 2008); thus the practitioner will pay attention to clients’ life development, including their current stage of life development as well as their life developmental history (Dobson & Dozois, 2010). However, the focus of change efforts is more likely to be anchored in the present, examining and working to reconstruct ways that current cognitive activity embedded in current environmental conditions are serving to sustain problematic patterns. Working Hypothesis Cognitive-behavioral theory is generally undertaken within an experimental frame of reasoning. That is, as the practitioner is identifying the cognitive content relating to the client’s present problem, the practitioner will also begin to develop and eventually refine a theory of the client’s presenting problem. This theory serves as a tentative working hypothesis of the problem and is the basis for the treatment plan and interventions with the client. In a working hypothesis, the practitioner will specify the relevant events, situations, or activities that activate the problematic core beliefs, which give rise to the unhelpful automatic thoughts and assumptions, which are followed by consonant emotional responding and maladaptive behaviors (Persons & Davidson, 2010). In short, this working hypothesis strives to operationalize on a case-by-case basis the mediational model components and how these appear to be functioning in producing outcomes distressing to the client. Thus, identifying the underlying core beliefs that may be causing the presenting problem, as well as what internal or external stimuli appear salient and activate the unhelpful beliefs, Dulmus, Catherine N., et al. Human Behavior in the Social Environment : Theories for Social Work Practice, John Wiley & Sons, Incorporated, 2012. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ncent-ebooks/detail.action?docID=980956. Created from ncent-ebooks on 2020-05-23 15:48:28. Cognitive-Behavioral Theory is critical and forms the basis of the working hypothesis (DeRubis et al., 2010; Persons, 2008). The working hypothesis is typically developed in an educational, collaborative manner with the client—assessing how the counselor’s picture fits with the client’s reported experiences and patterns—and is then used to target intervention efforts. Uses in Intervention Copyright © 2012. John Wiley & Sons, Incorporated. All rights reserved. Guided by this working theory, the practitioner, together with the client, use cognitive-behavioral theory to articulate interventions designed to modify a client’s unhelpful and problematic cognitions and to develop and reinforce adaptive and beneficial cognitive-affective-behavioral patterns. As discussed throughout this chapter, all human beings have this capacity to reflect on and alter their thinking. However, not all of us realize that we can develop these skills or know how to effectively apply these cognitive change skills. In this section, we review selected specific cognitive-behavioral intervention strategies that practitioners can use to help clients with their presenting problem. Cognitive-Behavioral Intervention Principles Cognitive-behavioral therapeutic interventions rely on two important principles. The first principle emphasizes the importance for clients, as well as practitioners, to understand the fundamentals of the mediational model and how thoughts are seen to interact with and influence feelings and behaviors (Dobson & Dozois, 2010). This reflects a transparent, educational orientation intended to assist clients to apply self-monitoring to gain awareness of their unique patterns, to reflectively assess dimensions of (mal)adaptiveness, to articulate and undertake change goals, and to marshal supports to reinforce and sustain desired changes in content and process. Toward these ends, a cognitive-behavioral practitioner will frequently use psychoeducational tools and strategies to teach clients about the fundamentals of the mediational model. The second fundamental principle of cognitive-behavioral interventions is the importance of collaboration between practitioner and client (J. S. Beck, 2011; Cormier et al., in press; Dobson & Dozois, 2010). Cognitive-behavioral interventions maintain that both the practitioner and the client bring expertise to the working, therapeutic relationship. Practitioners understand cognitive-behavioral theory and know how to create change in the lives of their clients. However, just as important to the success of cognitive therapy, clients bring their expertise about their thought content, ways of thinking, and meaning making. Without clients’ information about their internal thought processes, the practitioner cannot successfully apply the cognitive-behavioral theory to the presenting problem. Because of this, the success of cognitive-behavioral therapy replies on both the positive nature of the working relationship and the client’s level of participation during the change process (Leahy, 2008). Thus, it is critical that clients are active in the cognitive-behavioral interventions and the change process. Dulmus, Catherine N., et al. Human Behavior in the Social Environment : Theories for Social Work Practice, John Wiley & Sons, Incorporated, 2012. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ncent-ebooks/detail.action?docID=980956. Created from ncent-ebooks on 2020-05-23 15:48:28. 149 150 Human Behavior in the Social Environment Copyright © 2012. John Wiley & Sons, Incorporated. All rights reserved. Homework outside of meetings between the client and practitioner is frequently part of cognitive-behavioral interventions as one means to gather contextual information relevant to activating the problematic patterns and to practice the cognitive-behavioral change skills that clients are learning in formal sessions (J. S. Beck, 2011; Cormier et al., in press; DeRubis et al., 2010). One way the practitioner can help foster success with these application activities is to break the homework activities down into small, achievable parts (Kazantzis, Deane, Ronan, & L’Abate, 2005). The practitioner may also want to practice homework activities with clients or to coach clients through the activities during meetings to make certain the clients fully understand and are able to carry out the assignments. Last, it is important for practitioners to help clients think through barriers to carrying out the homework activities, as well as ways to work around these barriers. Although it is critical for clients to be active participants in the cognitive-behavioral change process both inside and outside of therapeutic meetings, it is also critical for the practitioner to fully prepare clients to be successful in their efforts. These principles combine to support empowerment outcomes. At the end of a successful collaborative working relationship between the client and practitioner, and with the resolution of the presenting problem, the client will have developed a new set of cognitive-behavioral change skills that will enable him or her to adaptively and effectively manage new problems. Once clients learn how to apply cognitive and behavioral change skills to one set of life problems, they are better positioned to generalize these skills to other problems in their life and to future problems. Strategies for Cognitive Change Dobson and Dozois (2010) distinguish three primary types of cognitivebehavioral therapies: coping skills therapies, problem-solving therapies, and cognitive restructuring therapies. Briefly, coping skills therapies aim to help clients more effectively manage biopsychosocial stressors and problems through the development and enhancement of coping skills. Problem-solving therapies aim to help clients find and create new strategies, skills, and resources to address their presenting problems. Cognitive restructuring therapies aim to create cognitive change to ameliorate clients’ presenting problem (Cormier et al., in press). Although these three cognitive-behavioral therapies entail specific strategies that distinguish them from one another, each involves some degree of cognitive restructuring. As a result, we focus our discussion of intervention strategies on cognitive restructuring. A key intervention strategy in cognitive restructuring involves asking clients to test the validity of their thoughts and beliefs, including both automatic thoughts and core beliefs. In considering the validity of a thought or belief, the client is asked to carefully assess whether the thought or belief is accurate, a fact, the truth, and meaningful. Frequently, problematic thoughts and beliefs rest on incomplete or distorted perceptions of relevant contributors and situational dynamics, may not be meaningful, or are not Dulmus, Catherine N., et al. Human Behavior in the Social Environment : Theories for Social Work Practice, John Wiley & Sons, Incorporated, 2012. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ncent-ebooks/detail.action?docID=980956. Created from ncent-ebooks on 2020-05-23 15:48:28. Copyright © 2012. John Wiley & Sons, Incorporated. All rights reserved. Cognitive-Behavioral Theory wholly accurate. Helping clients see how their unhelpful beliefs reflect biases or inaccuracies (such as confirming negative expectancies and discounting contradictory evidence) or are not meaningful is the beginning to cognitive change and is an important step in cognitive restructuring. One example of a specific intervention strategy is the downward arrow technique (Neenan & Dryden, 2004). In this technique the practitioner uses a series of questions following the client’s answers. For example, consider a client who has come to a practitioner because of difficulty with public speaking. The practitioner asks the client, ‘‘What is the worst thing possible that could happen to you while you are giving a talk in front of people?’’ The client tells the practitioner, ‘‘I get so anxious up there in front of everyone because I am so afraid that I’ll misspeak and make a complete fool out of myself.’’ The practitioner responds to the client with another question, such as, ‘‘Well, let’s say your worst fears came true. What would that mean to you?’’ This question may help the client begin to see that the consequences of misspeaking may not be quite as bad as she thinks, with subsequent questions helping to illuminate underlying beliefs about negative outcomes and their implications. Dobson and Dozois (2010) recommend that practitioners help clients distance themselves from unhelpful and problematic thoughts so they can identify, tolerate, and begin the process of challenging these seeming truths. This process of distancing can help the client examine the thoughts or beliefs in a more objective light. For example, in cognitive restructuring clients can be encouraged to take on the role of scientist or private detective with their thoughts and ways of thinking. In this role, the client will be looking for evidence to support or disconfirm the thought or belief. If in this process the client finds that there is little support for the thought or belief, the client may also begin to see the fallibility of the belief and the possibility of constructing alternatives. Cognitive restructuring interventions also help create helpful, positive, and adaptive cognitions to replace the unhelpful cognitions (Cormier et al., in press). Cognitive change is more likely to be successful and clients are less likely to slip back into unhelpful ways of thinking when armed with constructive, well-elaborated, and sustainable alternative response patterns. Again, let us consider the client who has difficulty with public speaking and has made progress in challenging her catastrophizing core beliefs and automatic thoughts. Toward developing positive, helpful thoughts about her public speaking, the practitioner may ask the client about a time in her past when she experienced success in a public presentation or, that failing, identify the kinds of thoughts she imagines a comfortable speaker would have in that context. Once the success is identified (e.g., ‘‘I was very anxious and nervous, but I kept thinking that if I kept taking a deep breath and focused on how well I really knew this material, I could get through it okay’’), the practitioner may build on this to coach and encourage the client to engage in positive self-talk during role-plays, exercises, and her next speaking engagement, guiding Dulmus, Catherine N., et al. Human Behavior in the Social Environment : Theories for Social Work Practice, John Wiley & Sons, Incorporated, 2012. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ncent-ebooks/detail.action?docID=980956. Created from ncent-ebooks on 2020-05-23 15:48:28. 151 152 Human Behavior in the Social Environment Copyright © 2012. John Wiley & Sons, Incorporated. All rights reserved. development of positive thoughts and core self-messages meaningful to the client. Likewise, the practitioner might couple this positive self-talk intervention with a behavioral intervention that emphasizes teaching the client relaxation breathing skills, which is an example of a coping skills strategy. In combination, the mitigation of the client’s negative beliefs (‘‘I make a complete fool of myself every time I speak in public’’), with the development of positive thoughts (‘‘I have given other talks and made it through them just fine. I can make it through this one’’), and the use of self-monitored self-talk, the client and practitioner have worked together to create a comprehensive cognitive restructuring intervention to address the client’s presenting problem. Changing Core Beliefs Although the cognitive change intervention strategies just described apply to automatic core beliefs as well as surface thoughts, practitioners may find it more challenging to restructure clients’ core beliefs relative to their automatic thoughts. Dowd (2002) posits that core beliefs are more stable and less alterable because they are long-standing and were once functional and adaptive (and they may continue to be adaptive and functional in other aspects of the client’s life). As a result, clients may be unwilling to consider and alter these beliefs. Berlin (2002) gives this apparent unwillingness a slightly different slant. She states that this unwillingness may be ‘‘an effort to preserve the integrity of continuous identity and a coherent life story’’ (p. 15). Thus, practitioners should carefully assess and consider problematic core beliefs in their efforts to change them, because unhelpful and problematic core beliefs may continue to give the client a sense of self and identity. Still, CBT literature often emphasizes the importance of changing problematic core beliefs if these appear to be causing problems in multiple areas of a client’s life or if other forms of skill development (such as coping or problem solving) will be insufficient. The practitioner may work with a client to change automatic thoughts at one time point, only to find a few months later that the client continues to struggle with the same presenting problem. A reoccurrence of a presenting problem suggests that an underlying core belief requires modification and restructuring. In a related vein, when clients and practitioners are successful in changing core beliefs to be more adaptive and helpful, clients will be provided with a kind of inoculation against future problems and difficulties because they have at their disposal a set of helpful, adaptive core beliefs that will aid them in facing future problems and challenges (Cormier et al., in press). Consistent with the cognitive restructuring interventions presented earlier, A. Beck (1996) maintains that there are three ways to change core beliefs: neutralize them, modify them, or create more adaptive core beliefs that inhibit and mitigate the maladaptive core beliefs. Thus, the same cognitive restructuring interventions that work effectively with automatic thoughts will also work on core beliefs. However, practitioners must realize and Dulmus, Catherine N., et al. Human Behavior in the Social Environment : Theories for Social Work Practice, John Wiley & Sons, Incorporated, 2012. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ncent-ebooks/detail.action?docID=980956. Created from ncent-ebooks on 2020-05-23 15:48:28. Cognitive-Behavioral Theory Copyright © 2012. John Wiley & Sons, Incorporated. All rights reserved. account for the fact that the foundational nature of core beliefs requires careful thought and active work on the part of both the client and the practitioner. Adapting Intervention Strategies Although the fundamental elements of cognitive-behavioral interventions can be successfully used to address a range of biopsychosocial problems across different groups of people, it is critical that these interventions be appropriately adapted to clients’ sociocultural, socioeconomic context and gender identity, cognitive development, and physical capacities and abilities. As discussed earlier in this chapter, cognitive-behavioral theory maintains that cognitive-affective-behavioral processes are similar across human beings. However, the content within the cognitive-affectivebehavioral processes is specific, unique, and personal to the individual. An individual’s cognitive content is, in part, derived from the individual’s cultural heritage and background, socioeconomic status, and the political realities of his or her existence, as well as his or her life history and life experiences. As a result, by adapting cognitive-behavioral interventions to the individual client’s background, life history, and experiences, the practitioner is helping to ensure the meaningfulness and ultimately the effectiveness of the interventions for that individual client. Fortunately, research provides some guidance on how to adapt cognitive-behavioral intervention strategies to be appropriate for various people (Voss Horrell, 2008). For example, in their assessment of a client’s presenting problem, it is important for practitioners to consider cognitions related to the presenting problem; in their formulation of a working hypothesis, they should consider how social and cultural factors may make a problem worse. As Berlin (2002, p. 149) states, ‘‘In the midst of all the other difficulties (i.e., social problems), the overwhelmed individual is less able to think his or her way through problems.’’ Thus practitioners should assess and recognize the client’s capacity to think through his or her problem in the face of the social problem with which the client may be struggling. Practitioners should also consider how social and environmental factors may limit a client’s ability to participate in the interventions and the change processes (Organista, 1995), as well as ways to assist clients to surmount barriers to their participation. Although for the most part, cognitive-behavioral change interventions emphasize intrapersonal change, some therapists also emphasize the importance of environment change. Practitioners who are able to help clients with changes to their environment, context, and situations as well as cognitivebehavioral changes may be the most effective change agents relative to practitioners who focus solely on cognitive-behavioral change. Changes to an individual’s environment, context, or situation will likely provide new experiences and new ways of seeing the self, the world, and the future. Moreover, significant reductions in environmental and social stressors will also likely help clients think their way through and out of a problem. Dulmus, Catherine N., et al. Human Behavior in the Social Environment : Theories for Social Work Practice, John Wiley & Sons, Incorporated, 2012. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ncent-ebooks/detail.action?docID=980956. Created from ncent-ebooks on 2020-05-23 15:48:28. 153 154 Human Behavior in the Social Environment Practitioners should carefully adapt their language when teaching clients cognitive-behavioral theory and the mediational model. For example, practitioners should use terms that do not discount the client’s life experiences or reinforce marginalization, such as using the terms rational and irrational when describing a client’s thoughts and thought processing. (Consider the terms we have used throughout the chapter to describe maladaptive cognitions, such as problematic and unhelpful.) Practitioners should also avoid jargon in their work with clients. As much as possible, practitioners should adapt the language used in cognitive-behavioral change interventions to the client’s primary language, age, educational level, and hearing, seeing, and reading abilities. Practitioners should also strive to adapt cognitive-behavioral intervention strategies to the client’s values and to address issues of discrimination and marginalization in the intervention work together, when appropriate (Carter, Sbrocco, Gore, Marin, & Lewis, 2003; Koh et al., 2002). Practitioners may need to consult and collaborate with others informed about a client group to better understand the situational and social problems with which their clients are struggling, as well as the internal meaning making in which their clients are engaged. Copyright © 2012. John Wiley & Sons, Incorporated. All rights reserved. Evidence-Based Foundations One reason for the advancement and expansion of CBT has been the rapidly growing body of empirical findings indicative of effective outcomes (Tolin, in press). The base of original research testing CBT outcomes is far too extensive to report here. However, a number of sources have summarized research outcomes across a range of clinical problems (Cormier et al., in press; Dobson, 2010; Nurius & Green, in press; O’Donohue & Fisher, 2009; Prochaska & Norcross, 2010; Simos, 2009): affective disorders (depression, anger, anxiety, panic, trauma, and phobia), addictions (substance abuse, gambling, smoking), obsessive-compulsive disorders, relationship problems (couples treatment, parenting, social ineffectiveness, assertion), self-esteem issues, problem-solving skill needs, stress management and coping skills, and medical conditions (pain, epilepsy, cancer, asthma). As previously noted, various forms of CBT have been applied with diverse client populations, across a wide age range, for both sexes, for gender-related issues, and with cultural and racial minorities. Cormier et al. (in press) and Hays and Iwamasa (2006) review some of these findings, indicating a generally positive record among published studies. However, these reviews and others also highlight the importance of explicit attention to cultural factors, at times indicating adaptations of CBT techniques (see Hays, 2008, for recommendations for cultural adaptation of cognitivebehavioral methods). Advances both in clinical research with diverse populations and in theorizing that better articulates cognitive-cultural and transactional models (e.g., DiMaggio, 2002; Whaley & Davis, 2007) are critical sources of input to guide cognitive-behavioral theory and method refinement for effectiveness. Dulmus, Catherine N., et al. Human Behavior in the Social Environment : Theories for Social Work Practice, John Wiley & Sons, Incorporated, 2012. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ncent-ebooks/detail.action?docID=980956. Created from ncent-ebooks on 2020-05-23 15:48:28. Cognitive-Behavioral Theory Copyright © 2012. John Wiley & Sons, Incorporated. All rights reserved. The growing pressures to use interventions established as empirically supported have combined with calls to distill key targets of change for particular problems and pressures to maximize cost and time efficiency to encourage research examining brief CBT. Although there are as yet no formal norms for what constitutes brief CBT, the generally recognized standard is treatment consisting of fewer than 10 sessions (in contrast to the more typical 10- to 20-session range for standard CBT treatment; Key & Craske, 2002). Brief CBT is generally targeted to a specified presenting problem and may be offered in a typical time sequence or in massed delivery, such as condensed over a 7- to 10-day period. Brief CBT may either reduce the amount of materials generally offered in standard CBT or may rely to a greater extent on the client taking a highly active role beyond time with the therapist, using materials such as workbooks, books, audiotapes, or computer programs. Similar to standard CBT, brief CBT has been effective for depression, anxiety, and phobia-related disorders (Beck & Bieling, 2004). Although the general body of research is favorable with respect to both CBT and brief CBT, as with many other therapies there remain gaps in our evidence base. For example, findings are incomplete as to which individual differences (e.g., attitudes toward treatment, chronicity and/or severity of problem, problem type) affect treatment outcome under what treatment conditions (Hazlett-Stevens & Craske, 2002). Thus far, evidence supporting effectiveness centers primarily on problems that are relatively circumscribed, with well-specified targets for change. However, to date there are few unconfounded comparisons between standard and brief CBT. Thus, further investigation is needed to ascertain the individuals and conditions under which brief CBT appears to be a well-suited choice over standard CBT. Critiques of This Approach Given the fuzzy definitional boundaries between behavior therapy, cognitive therapy, and cognitive-behavioral therapy, critiques are similarly indistinct. It is not always clear to what exactly critics are referring. Moreover, critiques of CBT, as with all clinical theories, vary somewhat as a function of the theoretical lens of the analyst. Some are uneasy with the highly systematic and perceived ‘‘mechanistic’’ characteristics inherited from behavior therapy, whereas others see that it is the behavioral techniques more than the focus on what are seen as ill-defined cognitions that carry the load of therapeutic change. Some find the focus on cognitions to be overly rationalistic and/or judgmental (e.g., regarding the irrationality of some cognitive patterns). Others argue that cognitive/behavioral therapy is too simplistic, basically reflects positive thinking, delivers little more than symptom relief, and is inattentive to client history or to dimensions of the therapeutic relationship. Not surprisingly, others rebuke such claims (see Neenan & Dryden, 2004; Prochaska & Norcross, 2010, for discussions). Some are concerned by what they see as insufficient attention to contextual factors in terms of socializing forces such as gender, sexual Dulmus, Catherine N., et al. Human Behavior in the Social Environment : Theories for Social Work Practice, John Wiley & Sons, Incorporated, 2012. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ncent-ebooks/detail.action?docID=980956. Created from ncent-ebooks on 2020-05-23 15:48:28. 155 Copyright © 2012. John Wiley & Sons, Incorporated. All rights reserved. 156 Human Behavior in the Social Environment identity mores, and culture, as well as the more direct effects of external contingencies (e.g., poverty, oppression) that do not have to ‘‘go through the head’’ to be felt and do damage to people (Kantrowitz & Ballou, 1992). Hays (1995) notes, for example, that some of the underlying tenets of CBT may not be well-suited for all clients, for example, emphasis on selfcontrol, greater focus on an individual’s thoughts relative to environmental factors that may be contributors to the root problems, challenging beliefs or thoughts that are seen as underlying client problems yet also reflect cultural or other personal values. On the other hand, strengths of cognitivebehavioral theory relative to use with culturally diverse people include its focus on individual uniqueness, empowerment and collaborative practice, conscious processes and specific events and behaviors, and recognition of variability in individual meaning and histories that are shaping current experience (Muroff, 2007). Recognition of need is incrementally being met with therapeutic adaptations and direct tests. Goodheart (2006) illustrates the attention to diversity factors and context and the blending of concepts from cognitive-behavioral therapy and other approaches. Other critiques illuminate gaps and weaknesses in testing the theoretical base of CBT. The theorized cognitive process underpinnings have not yet been thoroughly empirically modeled or tested as to their causative functions in producing change. Cognitive units such as schemas, associative networks, belief and expectancy systems, and priming functions are difficult to directly tap and test. In reviewing empirical shortcomings, Orsillo et al. (2004) and Hayes (2004a) review research highlighting the following: (a) insufficient demonstration of how irrational cognitions are acquired, who acquires them, and how they can be measured independent of the associated emotions, such as fear or anger; (b) lack of direct evidence to support the theoretical premise that cognition not only predicts but causes behavior; (c) findings of bidirectionality between cognitions and emotions, which raises questions as to temporal, causal processes; (d) the fact that clinical improvement has been observed with CBT before the key theorized features have been fully implemented; (e) component analysis that has been equivocal as to the additive benefits of cognitive interventions; and (f) changes in cognitive mediators, which are the presumed agents of change, that do not always explain outcomes of CBT. Increasing pressure to develop innovative theory and to secure outcomes evidence across groups or subpopulations is, in some cases, leading to new models that diverge from standard CBT theory and methods. There are also issues related to the match of CBT with client, problem, and therapist characteristics. This is particularly salient with short-form or abbreviated versions of CBT. Brief CBT is based on assumptions that a target for change is well-defined and circumscribed and that the client is motivated, ready to undertake focused cognitive and behavioral changes, and capable of active engagement in activities in and between intervention sessions (Beck & Bieling, 2004). However, in many cases, neither the problem nor the client is consistent with these assumptions, which raises serious questions about the appropriateness of brief CBT in these instances Dulmus, Catherine N., et al. Human Behavior in the Social Environment : Theories for Social Work Practice, John Wiley & Sons, Incorporated, 2012. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ncent-ebooks/detail.action?docID=980956. Created from ncent-ebooks on 2020-05-23 15:48:28. Cognitive-Behavioral Theory Copyright © 2012. John Wiley & Sons, Incorporated. All rights reserved. (Hazlett-Stevens & Craske, 2002). In a related vein, there needs to be good match with therapist characteristics. For example, therapists need a high level of skill in effecting change in a limited time, positive expectancies, an ability to work in a highly targeted manner, and openness to outcomes being framed more in terms of teaching skills than in full symptom resolution (Key & Craske, 2002). These issues are by no means unique to CBT. In many respects, they reflect the ongoing nature of advances in social science theory, clinical application, and changing consciousness and value perspectives that characterize society at large as well as clinical and research communities. Examples include assertions of the need for greater contextualism, the impact of postmodern and postcolonial theories, the need for inclusion of cultural diversity factors, and calls for multilevel theorizing that links individual with structural forces toward problem development and effective interventions—which bring challenging forces to bear on all practicerelated theories. Part of what has characterized CBT theory is its elasticity. That is, the essential cognitive paradigm has been applied and adapted to a remarkably broad array of clinical problems. As both Hayes et al. (2004) and Scrimali and Grimaldi (2004) illustrate, there is an ongoing flow to clinical and scientific clinical movements that illuminates limitations in conjunction with new possibilities. Cognitive-behavioral theory reflects the ebb and flow of research findings; theoretical challenges and innovations; and pragmatic, ‘‘on the ground’’ clinical implementation feedback. As more is being learned about the complex systems that contribute to our functioning as humans—both internally and in self-social exchanges—we anticipate that cognitive-behavioral theory and its theoretical successors will evolve as well. Key Terms Active agents Automatic thought Cognitive errors Cognitive restructuring Core beliefs Information processing Metacognition Self-regulation Thought record log Working hypothesis Review Questions for Critical Thinking 1. Explain how cognitive behavioral theory conceptualizes the relationships among thoughts, feeling, and behaviors. 2. Compare and contrast the difference between automatic thoughts and core beliefs. How are they both similar and different? What is their relationship to one another? Dulmus, Catherine N., et al. Human Behavior in the Social Environment : Theories for Social Work Practice, John Wiley & Sons, Incorporated, 2012. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ncent-ebooks/detail.action?docID=980956. Created from ncent-ebooks on 2020-05-23 15:48:28. 157 158 Human Behavior in the Social Environment 3. In your own words, explain information processing. Explain how human beings’ information processing systems can be both helpful and unhelpful for human beings. 4. In your own words and ideas, explain the mediational model from cognitive behavioral theory. Explain the importance of the mediational model for the creation of therapeutic change in cognitivebehavioral therapy. 5. In your own words and ideas, explain the idea of metacognition. Explain the importance of metacognition for the creation of therapeutic change in cognitive-behavioral therapy. 6. Explain how a person’s context and environment are relevant and important in conducting cognitive-behavioral therapy. Copyright © 2012. John Wiley & Sons, Incorporated. All rights reserved. Online Resources Beck Institute for Cognitive Behavioral Therapy (www.beck institute.org). The Beck Institute is a training and resource center for health and mental health professionals, educators, and students that offers training programs and resources in cognitive-behavioral therapy. The American Institute for Cognitive Therapy (www.cognitive therapynyc.com), headed by Dr. Robert Leahy, provides evaluations and treatment for psychological problems, state-of-the-art cognitive-behavioral therapy, and training for other professionals. The Schema Therapy Institute (www.schematherapy.com/id201.htm), headed by Dr. Jeffrey Young, focuses on schema theory and schemabased approaches to cognitive therapy. Similar to other institutes, this one provides training, assessment tools, consultation, and other practice-oriented resources. The American Psychological Association (http://search.apa.org/ search?query=cognitive-behavioral therapy) provides a wide range of resources related to cognitive behavioral therapy, include publications, web page recommendations, media sources, and direction to applications for varied audiences. Seeking Safety (www.seekingsafety.org). Seeking Safety is a manualized, evidence-based cognitive-behavioral therapy that helps clients with co-occurring trauma (e.g., Posttraumatic Stress Disorder and substance abuse). TF-CBT Web (http://tfcbt.musc.edu). This is a free web-based learning course for trauma-focused cognitive-behavioral therapy, which is an evidence-based therapy for children and youth who have experienced a traumatic event (e.g., auto accident, child sexual abuse, natural disaster). Dulmus, Catherine N., et al. Human Behavior in the Social Environment : Theories for Social Work Practice, John Wiley & Sons, Incorporated, 2012. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ncent-ebooks/detail.action?docID=980956. Created from ncent-ebooks on 2020-05-23 15:48:28. Cognitive-Behavioral Theory Copyright © 2012. John Wiley & Sons, Incorporated. All rights reserved. References Alford, B. A., & Beck, A. T. (1997). The integrative power of cognitive therapy. New York, NY: Guilford Press. Arch, J. J., & Craske, M. G. (2009). First-line treatment: A critical appraisal of cognitive behavioral therapy developments and alternatives. Psychiatric Clinics of North America, 32(3), 525–547. doi:10.1016/j.psc.2009.05.001. Baer, R. A. (2002). Mindfulness training as a clinical intervention: A conceptual and empirical review. Clinical Psychology: Science and Practice, 10, 125–143. Beck, A. T. (1996). Beyond belief: A theory of modes, personality and psychopathology. In P. M. Salkovskis (Ed.), Frontiers of cognitive therapy (pp. 1–25). New York, NY: Guilford Press. Beck, A. T. (2002). Cognitive models of depression. In R. L. Leahy & E. T. Dowd (Eds.), Clinical advances in cognitive psychotherapy theory and application (pp. 29–61). New York, NY: Springer. Beck, A. T. (2005). The current state of cognitive therapy: A 40-year retrospective. Archives of General Psychiatry, 62, 953–959. Beck, J. S. (1995). Cognitive therapy basics and beyond. New York, NY: Guilford Press. Beck, J. S. (2011). Cognitive therapy: Basics and beyond (2nd ed.). New York, NY: Guilford Press. Beck, J. S., & Bieling, P. J. (2004). Cognitive therapy: Introduction to theory and practice. In M. J. Dewan, B. N. Steenbarger, & R. P. Greenberg, (Eds.), The art and science of brief psychotherapies: A practitioner’s guide (pp. 15–49). Washington, DC: American Psychiatric Press. Berlin, S. B. (2002). Clinical social work practice: A cognitive-integrative perspective. New York, NY: Oxford University Press. Bowen, S., Chawla, N., & Marlatt, G. A. (2011). Mindfulness-based relapse prevention for addictive behaviors: A clinician’s guide. New York, NY: Guilford Press. Carter, M. M., Sbrocco, T., Gore, K. L., Marin, N. W., & Lewis, E. I. (2003). Cognitive-behavioral group therapy versus a wait-list control in the treatment of African American women with panic disorder. Cognitive Therapy and Research, 27, 508–518. Christensen, A., Atkins, D. C., Berns, S., Wheeler, J., Baucom, D. H., & Simpson, L. E. (2004). Traditional versus integrative behavioral couple therapy for significantly and chronically distressed married couples. Journal of Consulting and Clinical Psychology, 72, 176–191. Christner, R. W., Stewart, J. L., & Freeman, A. (Eds.). (2007). Handbook of cognitive-behavior group therapy with children and adolescents: Specific settings and presenting problems. New York, NY: Routledge. Cormier, S., Nurius, P. S., & Osborn, C. J. (in press). Interviewing and change strategies for helpers (7th ed.). Pacific Grove, CA: Cengage. DeRubis, R. J., Tang, T. Z., & Beck, A. T. (2010). Cognitive therapy. In K. S. Dobson (Ed.), Handbook of cognitive-behavioral therapies (3rd ed., pp. 277–316). New York, NY: Guilford Press. DiMaggio, P. (2002). Why cognitive (and cultural) sociology needs cognitive psychology. In K. A. Cerulo (Ed.), Culture in mind: Toward a sociology of culture and cognition (pp. 272–281). New York, NY: Routledge. Dulmus, Catherine N., et al. Human Behavior in the Social Environment : Theories for Social Work Practice, John Wiley & Sons, Incorporated, 2012. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ncent-ebooks/detail.action?docID=980956. Created from ncent-ebooks on 2020-05-23 15:48:28. 159 Copyright © 2012. John Wiley & Sons, Incorporated. All rights reserved. 160 Human Behavior in the Social Environment Dimeff, L., & Koerner, K. (Ed.). (2007). Dialectical behavior therapy in clinical practice: Applications across disorders and settings. New York, NY: Guilford Press. Dobson, K. S. (Ed.). (2010). Handbook of cognitive-behavioral therapies (3rd ed.). New York, NY: Guilford Press. Dobson, K. S., & Dozois, D. J. A. (2010). Historical and philosophical bases of the cognitive-behavioral therapies. In K. S. Dobson (Ed.), Handbook of cognitive-behavioral therapies (3rd ed., pp. 3–38). New York, NY: Guilford Press. Dowd, E. T. (2002). History and recent developments in cognitive psychotherapy. In R. L. Leahy & E. T. Dowd (Eds.), Clinical advances in cognitive psychotherapy theory and application (pp. 15–28). New York, NY: Springer. Dunkley, D. M., Blankstein, K. R., & Segal, Z. V. (2010). Cognitive assessment. In K. S. Dobson (Ed.), Handbook of cognitive-behavioral therapies (3rd ed., pp. 133–171). New York, NY: Guilford Press. Foreyt, J. P., & Goodrick, G. K. (2001). Cognitive behavior therapy. In R. Corsini (Ed.), Handbook of innovative therapy (2nd ed., pp. 95–108). New York, NY: Wiley. Gilboa-Schechtman, E., & Foa, E. B. (2001). Patterns of recovery from trauma: The use of intraindividual analysis. Journal of Abnormal Psychology, 110, 392–400. Goodheart, C. D. (2006). Evidence, endeavor, and expertise in psychology practice. In C. D. Goodheart, A. E. Kazdin, & R. J. Sternberg (Eds.), Evidence-based psychotherapy: Where practice and research meet (pp. 37–61). Washington, DC: American Psychological Association. Hayes, S. C. (2004a). Acceptance and commitment therapy and the new behavior therapies: Mindfulness, acceptance, and relationship. In S. C. Hayes, V. M. Folette, & M. M. Linehan (Eds.), Mindfulness and acceptance: Expanding the cognitive-behavioral tradition (pp. 1–29). New York, NY: Guilford Press. Hayes, S. C. (2004b). Acceptance and commitment therapy, relational frame theory, and the third wave of behavioral and cognitive therapies. Behavior Therapy, 35, 639–665. Hayes, S. C., Folette, V. M., & Linehan, M. M. (Eds.). (2004). Mindfulness and acceptance: Expanding the cognitive-behavioral tradition. New York, NY: Guilford Press. Hays, P. A. (1995). Multicultural applications of cognitive behavioral therapy. Professional Psychology: Research and Practice, 26, 309–315. Hays, P. A. (2008). Addressing cultural complexities in practice: Assessment, diagnosis, and therapy (2nd ed.). Washington, DC: American Psychological Association. Hays, P. A., & Iwamasa, G. Y. (2006). Culturally responsive cognitive-behavioral therapy. Washington, DC: American Psychological Association. Hazlett-Stevens, H., & Craske, M. G. (2002). Brief cognitive-behavioral therapy: Definition and scientific foundations. In F. W. Bond & W. Dryden (Eds.), Handbook of brief cognitive behaviour therapy (pp. 1–20). Chichester, West Sussex, UK: Wiley. Iverson, K. M., Gradus, J. L., Resick, P. A., Suvak, M. K., Smith, K. F., & Monson, C. M. (2011). Cognitive–behavioral therapy for PTSD and depression symptoms reduces risk for future intimate partner violence among interpersonal trauma survivors. Journal of Consulting and Clinical Psychology, 79(2), 193–202. Dulmus, Catherine N., et al. Human Behavior in the Social Environment : Theories for Social Work Practice, John Wiley & Sons, Incorporated, 2012. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ncent-ebooks/detail.action?docID=980956. Created from ncent-ebooks on 2020-05-23 15:48:28. Copyright © 2012. John Wiley & Sons, Incorporated. All rights reserved. Cognitive-Behavioral Theory Kantrowitz, R., & Ballou, M. (1992). A feminist critique of cognitive-behavioral therapy. In L. S. Brown & M. Ballou (Eds.), Personality and psychopathology: Feminist reappraisals (pp. 70–87). New York, NY: Guilford Press. Kazantzis, N., Deane, F. P., Ronan, K. R., & L’Abate, L. (Eds.). (2005). Using homework assignments in cognitive behavior therapy. New York, NY: Routledge. Key, F. A., & Craske, M. G. (2002). Assessment issues in brief cognitive-behavioral therapy. In F. W. Bond & W. Dryden (Eds.), Handbook of brief cognitive behaviour therapy (pp. 21–34). Chichester, West Sussex, UK: Wiley. Koh, L. P., Oden, T., Munoz, R. F., Robinson, A., & Leavitt, D. (2002). Adapted cognitive behavioral group therapy for depressed low-income African American women. Community Mental Health Journal, 38, 497–504. Laidlaw, K., Thompson, L. W., Dick-Siskin, L., & Gallagher-Thompson, D. (2003). Cognitive behavioral therapy with older people. West Sussex, UK: John Wiley & Sons. Lau, A.W., & Kinoshita, L.M. (2006). Cognitive-behavioral therapy with culturally diverse older adults. In P. A. Hays & G. Y. 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Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder. New York, NY: Guilford Press. Macy, R. J. (2006). Cognitive therapy theory. In A. Rochlen (Ed.), Applying counseling theories: An online, case-based approach (pp. 157–176). Upper Saddle River, NJ: Pearson. Mahoney, M. J. (1995). Theoretical developments in the cognitive psychotherapies. In M. J. Mahoney (Ed.), Cognitive and constructive psychotherapies (pp. 3–19). New York, NY: Springer. Mahoney, M. J. (2004a). Human change processes and constructive psychotherapy. In A. Freeman, M. J. Mahoney, P. Devito, & D. Martin (Eds.), Cognition and psychotherapy (2nd ed., pp. 5–24). New York, NY: Springer. Mahoney, M. J. (2004b). Synthesis. In A. Freeman, M. J. Mahoney, P. Devito, & D. Martin (Eds.), Cognition and psychotherapy (2nd ed., pp. 349–365). New York, NY: Springer. Manassis, K. (2009). Cognitive behavioral therapy with children: A guide for the community practitioner. New York, NY: Routledge. 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New York, NY: Guilford Press. Muroff, J. (2007). Cultural diversity and cognitive behavior therapy. In T. Ronen & A. Freeman, (Eds.), Cognitive behavior therapy in clinical social work practice ( pp. 109–146). New York, NY: Springer. Neenan, M., & Dryden, W. (2004). Cognitive therapy: 100 key points and techniques. New York, NY: Brunner-Routledge. Nezu, A. M., & Nezu, C. M. (2010). Cognitive-behavioral case formulation and treatment design. In R. A. DiTomasso, B. A. Golden, & H. J. Morris (Eds.), Handbook of cognitive-behavioral approaches in primary care (pp. 201–222). New York, NY: Springer. Nurius, P. S. (1991). Possible selves and social support: Social cognitive resources for coping and striving. In J. Howard & P. Callero (Eds.), The self-society dynamic (pp. 239–258). Cambridge, UK: Cambridge University Press. Nurius, P. S. (2008). Cognition and social cognitive theory. In T. Mizrahi & L. Davis (Eds.), Encyclopedia of social work (20th ed.). Washington, DC: NASW. Nurius, P. 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The case formulation approach to cognitive-behavior therapy. New York, NY: Guilford Press. Persons, J. B., & Davidson, J. (2010). Cognitive-behavioral case formulation. In K. S. Dobson (Ed.), Handbook of cognitive-behavioral therapies (3rd ed., pp. 172–195). New York. NY: Guilford Press. Prochaska, J. O., & Norcross, J. C. (2010). Systems of psychotherapy: A transtheoretical analysis (75th ed.). Pacific Grove, CA: Thompson/Brooks/Cole. Roemer, L. & Orsillo, S. M. (2009). Mindfulness- and acceptance-based behavioral therapies in practice. New York, NY: Guilford Press. Ronen, T., & Freeman, A. (Eds.). (2007). Cognitive behavior therapy in clinical social work. New York, NY: Springer. Roth, B., & Calle-Mesa, L. (2006). Mindfulness-based stress reduction (MBSR) with Spanish- and English-speaking inner-city medical patients. In R. A. Baer (Ed.). Mindfulness-based treatment approaches (pp. 263–284). New York, NY: Academic Press. Dulmus, Catherine N., et al. Human Behavior in the Social Environment : Theories for Social Work Practice, John Wiley & Sons, Incorporated, 2012. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ncent-ebooks/detail.action?docID=980956. Created from ncent-ebooks on 2020-05-23 15:48:28. Cognitive-Behavioral Theory Copyright © 2012. John Wiley & Sons, Incorporated. All rights reserved. Safran, J. D., Eubanks-Carter, C., & Muran, J. C. (2010). Emotion focused/interpersonal cognitive therapy. In N. Kazantzis, M. A. Reinecke, & A. Freeman (Eds), Cognitive and behavioral theories in clinical practice (pp. 332–362). New York, NY: Guilford Press. Scrimali, T., & Grimaldi, L. (2004). The entropy of mind: A complex systemsoriented approach to psychopathology and cognitive psychotherapy. In A. Freeman, M. J. Mahoney, P. Devito, & D. Martin (Eds.), Cognition and psychotherapy (2nd ed., pp. 297–322). New York, NY: Springer. Segal, Z. V., Williams, J. M., & Teasdale, J. D. (2002). Mindfulness-based cognitive therapy for depression: A new approach to preventing relapse. New York, NY: Guilford Press. Shapiro, S. L. & Carlson, L. E. (2009). The art and science of mindfulness. Washington, DC: American Psychological Association. Simos, G. (Ed). (2009). Cognitive behavior therapy: A guide for the practicing clinician, vol. 2. New York, NY: Routledge/Taylor & Francis. Tolin, D. F. (2010). Is cognitive-behavioral therapy more effective than other therapies? A meta-analytic review. Clinical Psychology Review, 30, 710–720. doi:10.1016/j.cpr.2010.05.003. Voss Horrell, S. C. (2008). Effectiveness of cognitive–behavioral therapy with adult ethnic minority clients: A review. Professional Psychology: Research and Practice, 39(2), 160–168. doi:10.1037/0735–7028.39.2.160. Weisz, J. R., & Kazdin, A. E. (Eds.). (2010). Evidence-based psychotherapies for children and adolescents. New York, NY: Guilford Press. Whaley, A. L., & Davis, K. E. (2007). Cultural competence and evidence-based practice in mental health services: A complementary perspective. American Psychologist, 62, 563–574. Young, J. E., Rych, J. I., Weinberger, A. D., & Beck, A. T. (2008). Cognitive therapy for depression. In D. H. Barlow (Ed.), Clinical handbook of psychological disorders (4th ed., pp. 250–305). New York, NY: Guilford Press. Dulmus, Catherine N., et al. Human Behavior in the Social Environment : Theories for Social Work Practice, John Wiley & Sons, Incorporated, 2012. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ncent-ebooks/detail.action?docID=980956. Created from ncent-ebooks on 2020-05-23 15:48:28. 163 Copyright © 2012. John Wiley & Sons, Incorporated. All rights reserved. Dulmus, Catherine N., et al. Human Behavior in the Social Environment : Theories for Social Work Practice, John Wiley & Sons, Incorporated, 2012. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ncent-ebooks/detail.action?docID=980956. 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