According to Bandura ( 1997, 1982a, b ) , the primary factor in the determination of a stressful event is the individual’s perceived inef fi ciency in coping with or control- ling a potentially aversive event. We now review several models of cognitively based psychotherapeutic interventions that may be employed to alter the patient’s percep- tion (cognitive interpretation) of an environmental transaction that might be seen as potentially aversive.
Ellis’s Model
Modern cognitive therapy is considered to have emerged in 1955, when Albert Ellis developed rational-emotive therapy (RET; Arnkoff & Glass, 1992 ) . Ellis ( 1971,
1973, 1984, 1991 ) has proposed that individuals often acquire irrational or illogical cognitive interpretations or beliefs about themselves or their environment. The extent to which these beliefs are irrational and important corresponds to the amount of emotional distress experienced by the individual. Ellis believes that the emotional disturbance experienced by the individual can be summarized using the following
“A-B-C” model:
→ →
A B C
Activating experience Belief Emotional consequence In Condition A, some environmental transaction involving the individual occurs (e.g., he or she is late for an appointment). In Condition B, the person generates
some “irrational” belief about him- or herself based on the original experience (e.g., “I’m stupid, worthless, incompetent for being late”). Condition C represents the emotional consequence (e.g., guilt, depression, shame, or anxiety) that results, not from the experience itself (A) but directly from the irrational belief (B). Ellis then employs his model of RET, which consists of adding a “D” to the A-B-C para- digm, representing a conscious effort to “dispute” the irrational cognitive belief that resulted in the emotional distress. The RET therapist may use techniques such as debating, role playing, social skills training, and bibliotherapy to challenge the indi- vidual’s beliefs, often in a confrontational, forceful fashion. Therefore, regardless of the techniques used, the overall psychotherapeutic goal is to alter the individual’s interpretation. Ellis has delineated a series of questions to assist in the disputation of irrational beliefs (see Table 8.1 ).
Beck’s Cognitive Therapy Model
The cognitive therapy process of Aaron T. Beck is considered the second major cognitive restructuring therapy (Arnkoff & Glass, 1992 ) . Similar to RET, cognitive therapy assists the client in identifying maladaptive thinking and persuades him or her to develop a more adaptive view. However, whereas RET is more philosophi- cally driven (Ellis, 1995), Beck’s cognitive therapy is more empirically based and focuses on whether thoughts and beliefs are realistic compared to whether they are rational (Meichenbaum, 1995 ) . As Beck ( 1995 ) notes,
Based on my clinical observations and some systematic clinical studies and experiments, I theorized that there was a thinking disorder at the core of the psychiatric syndromes such as depression and anxiety. This disorder was re fl ected in a systematic bias in the way the patients interpreted particular experiences. (vii)
Beck differentiates between three types of cognitions that may be involved in disrupted thinking: automatic thoughts, schemas, and cognitive distortions.
Automatic thoughts are considered a “surface level” cognition that is brought to awareness quickly and readily, and leads directly to the individual’s emotional and behavioral responses. Cognitive schemas are thought of as internal models of aspects of the self and the environment, and are used to process information. They often lead individuals with emotional problems to develop perceptions of threat,
Table 8.1 Disputing irrational beliefs 1. What irrational belief needs to be disputed?
2. Can this belief be rationally supported?
3. What evidence exists for the falseness of this belief?
4. Does an evidence exist for the truth of this belief?
5. What worse things could actually happen to me if my initial experience (activating experi- ence) does not end favorably?
6. What good things can I make happen even if my initial experience does not end favorably?
loss, or danger. Cognitive distortions serve in essence as a link between dysfunctional schemas and automatic thoughts. For example, when new information is processed cognitively, the material may be biased or skewed in order to make it consistent with a current schema.
Then, to challenge the patient’s maladaptive thinking, Beck encourages the use of a Socratic dialogue, which relies on the ability of the treating therapist to ask questions in a probing manner that allows the patient to answer in a way to persuade him- or herself to think differently. Beck and Emery ( 1985 ) describe in elaborate detail how cognitive restructuring principles can be used in the treatment of anxiety and stress-related disorders: “Anxious patients in the simplest terms believe,
‘Something bad is going to happen that I won’t be able to handle.’ The cognitive therapist uses three basic strategies or questions to help the patient restructure this thinking” (p. 200):
1. What is the evidence supporting the conclusion currently held by the patient?
2. What is another way of looking at the same situation but reaching some other conclusion?
3. What will happen if, indeed, the currently held conclusion/opinion is correct?
While examining each of these three strategic questions, it is important to keep in mind that individual differences may affect a patient’s responses. It is also worth acknowledging that the therapist may need to employ all three strategies throughout therapy.
1. What is the evidence? One goal of this strategy is to analyze the patient’s cogni- tive patterns and search for “faulty logic.” Therapists may help patients to correct faulty logic and ideas through questioning techniques that may allow them better to clarify the meaning(s) and de fi nitions of the problem. According to Beck ( 1993 ) , individuals experiencing stress reactions tend to personalize events not relevant to them (egocentrism) and interpret situations in global and absolute terms. Therefore, the following are typical questions used to improve the patient’s ability to process information and test reality:
What is the evidence supporting this conclusion?
•
What is the evidence against this conclusion?
•
Are you oversimplifying causal relationships?
•
Are you confusing habits or commonly held opinions with fact?
•
Are your interpretations too far removed from your actual experiences?
•
Are you thinking in “all-or-nothing” terms (i.e., black–white, either–or, on–
•
off, or all-or-none types of decisions and outcome)?
Are your conclusions in any way extreme or exaggerated?
•
Are you taking selected examples out of context and basing you conclusion
•
on such information?
Is the source of information reliable?
•
Is your thinking in terms of certainties rather than probabilities?
•
Are you confusing low-probability with high-probability events?
•
Are you basing your conclusions on feelings or values rather than facts?
•
Are you focusing on irrelevant factors in forming your conclusions?
•
Through the use of such questions, patterns of faulty reasoning, such as
•
projections, exaggerations, and negative attributions, may be discovered and corrected.
2. What is another way of looking at it? The goal of this strategy is to help the patient generate alternative interpretations in lieu of the interpretation currently held. Strategies such as increasing both objectivity and perspective, and shifting or diverting cognitive set (Beck, 1993 ) may lead to reattribution, diminishing the signi fi cance of the environmental transaction, or even restructuring the transac- tion to fi nd something positive in the event.
3. So what if it happens? The goal of this strategy is to help the patient “decatastro- phize” the environmental transaction as well as to develop coping strategies and problem-solving skills. It will be recalled from the multidimensional treatment model that “environmental engineering” (Girdano, Everly, & Dusek, 1997 ) and
“problem solving” are merely terms that describe the therapeutic processes of this third strategic phase of therapy as described by Beck and Emery ( 1985 ) . These authors suggest that “therapist and patient collaboratively develop a vari- ety of strategies that the person can use” (p. 208). Ultimately, the goal of therapy is to allow the patient to develop autonomous skills in each of the three strategic areas mentioned previously. The notions of “environmental engineering” and
“problem solving” will be more formally integrated in the next model—Meichen- baum’s stress inoculation training mode.
Meichenbaum’s Stress Inoculation Training
Using the principles contained in his classic text, Cognitive-Behavior Modi fi cation, Meichenbaum ( 1977 ) developed a specialized, cognitively based therapy for the treatment of excessive stress in a therapeutic formulation called “stress inoculation training” (SIT).
Meichenbaum ( 1993 ) , re fl ecting on 20 years of SIT, notes:
In short, SIT helps clients acquire suf fi cient knowledge, self-understanding, and coping skills to facilitate better ways of handling expected stressful encounters. SIT combines ele- ments of Socratic and didactic teaching, client self-monitoring, cognitive restructuring, problem solving, self-instructional and relaxation training, behavioral and imagined rehearsal, and environmental change. With regard to the notion of environmental change, SIT recognizes that stress is transactional in nature. (p. 381)
The SIT paradigm consists of an overlapping, three-phase intervention (Meichenbaum, 2007 ) . The fi rst phase, the initial conceptualization phase, includes the development of a collaborative relationship between the client and trainer through the use of Socratic exchanges. The overall objectives of this phase include data collection and education to help clients reconceptualize their stressful experi- ences in a more hopeful and empowered manner.
In the second phase of SIT, coping and problem-solving skills are taught and rehearsed. Table 8.2 provides examples of self-statements that may be used as coping techniques. Skills acquisition in this phase encompasses more than self-statements.
Assertion training, anger control, study skills, parenting, and relaxation may be incorporated.
The third phase of SIT, application and follow-through, allows patients to apply the skills acquired in the preceding two phases across situations with increasing levels of actual stress. Therefore, techniques such as modeling, role playing, and in vivo exposure are used, as well as features of relapse prevention. The follow-up component allows for future extension of SIT uses.
These three phases of SIT are enumerated in greater detail in Table 8.3 . (A valuable guide for practitioners on the use of SIT is also available; see Meichenbaum, 1985, 2007 .)
Table 8.2 Examples of coping self-statements rehearsed in stress inoculation training Preparing for a stressor
• What is it you have to do?
• You can develop a plan to deal with it
• Just think about what you can do about it. That’s better than getting anxious • No negative self-statements: Just think rationally
• Don’t worry: Worry won’t help anything
• Maybe what you think is anxiety is eagerness to confront the stressor Confronting and handling a stressor
• Just “psych” yourself up—you can meet this challenge
• You can convince yourself to do it. You can reason your fear away • One step at a time: You can handle the situation
• Don’t think about fear; just think about what you have to do. Stay relevant
• This anxiety is what the doctor said you would feel. It’s reminder to use your coping exercises
• This tenseness can be an ally; a cue to cope • Relax; you’re in control. Take a slow deep breath • Ah, good
Coping with the feeling of being overwhelmed • When fear comes, just pause
• Keep the focus on the present; what is it you have to do?
• Label your fear from 0 to 10 and watch it change • You should expect your fear to rise
• Don’t try to eliminate fear totally; just keep it manageable Reinforcing self-statements
• It worked; you did it
• Wait until you tell your therapist (or group) about this • It wasn’t as bad as you expected
• You made more out of your fear than it was worth
• Your damn ideas—that’s the problem. When you control them, you control your fear • It’s getting better each time you use the procedures
• You can be pleased with progress you’re making • You did it!
Source : D. Meichenbaum ( 1977 ) . Cognitive Behavior Modi fi cation. Copyright by Plenum Press.
Reprinted by permission.
Table 8.3 Flowchart of stress inoculation training Phase One: Conceptualization
(a) Data collection—integration
• Identify determinants of problem via interview, image-based reconstruction, self-monitoring, psychological and environmental assessments, and behavioral observance
• Allow the client to tell his or her own story and help the description to be broken down into behaviorally speci fi c terms
• Formulate treatment plan. Have the client establish short-term, intermediate, and long-term behaviorally speci fi c goals
• Introduce integrative conceptual model (b) Assessment skills training
• Distinguish between performance failure and skill de fi cit
• Train clients to analyze problems independently (e.g., conduct situational and developmental analyses and to seek discon fi rmatory data)
• Formulate a reconceptualization of the client’s stress while encouraging the client and bringing to light his or her strength’s and bolstering feelings of resourcefulness Phase Two: Skills Acquisition and Rehearsal
(a) Skills training
• Training instrumental coping skills (e.g., communication assertion, anxiety management, problem solving, relaxation training, parenting, study skills)
• Train emotionally focused palliative coping skills (e.g., perspective-taking, attention diversion, use of social supports, adaptive affect expression, relaxation)
• Aim to develop an extensive repertoire of coping responses to facilitate fl exible responding (b) Skills rehearsal
• Promote smooth integration and execution of coping responses via imagery and role play • Use coping modeling including collaborative discussion, practice and feedback • Use self-instructional training to develop internal mediators to self-regulate coping
responses
Phase Three: Application and Follow-Through (a) Induce application of skills
• Prepare for application using coping imagery, using early stress cues as signals for coping • Role -play-anticipated stressful situations and encourage adoption of “role play” attitude in
real world
• Exposure to in-session-graded stressors
• Use of graded exposure and other response induction aids to foster in vivo responding and building self-ef fi cacy
• Use relapse prevention procedures (e.g., identifying high-risk situations, anticipate possible stressful reactions, and practice coping responses)
(b) Maintenance and generalization
• Slowly phase out treatment and arrange follow-up sessions and review
• Involve others in client’s life (e.g., parents, spouse, doctors) and encourage the use of peer and self-help groups
• Encourage the client to coach someone with a similar problem
• Build a sense of coping self-ef fi cacy in relation to situations clients sees as high risk, as well as developing coping strategies to deal with recovery from failures and setbacks General guidelines for training
• Attend to referral and intake process
(continued)
Table 8.3 (continued)
• Establish realistic expectations regarding course and outcome of therapy • Foster optimism and con fi dence by structuring incremental success experiences • Respond to stalled progress with problem solving versus labeling client resistant
Sources : Adapted from “Stress Inoculation Training: Toward a Paradigm for Training Coping Skills” by D. Meichenbaum and R. Cameron in Stress Reduction and Prevention (p. 121) edited by D. Meichenbaum and M. E. Jaremko. Copyright 1983 by Plenum Press, and D. Meichenbaum ( 2007 ) Stress inoculation training. A preventative and treatment approach. In P. M. Lehrer, R. L.
Woolfolk, & W. E. Sime (Eds). Principles and practice of stress management (3rd ed., pp. 506–507).
New York: Guilford
Meichenbaum’s SIT training is of special interest in this volume because it manifests the belief that stress management is most effective when it is fl exible and multidimensional. Similarly, SIT allows us to integrate the concept of “environmental engineering” as delineated in the treatment model described in the introduction to Part II. The term environmental engineering, it will be recalled, is borrowed from the work of Girdano, Dusek, and Everly (2001) as it was fi rst described in 1979, and refers to any conscious attempts at manipulating environmental factors to reduce one’s exposure to stressor events. Both proactive, environmental change and reac- tive problem solving must be included under this heading. The reader will observe that there are different points within the model wherein problem solving, or any other form of environmental engineering, is obviously applicable.
As implied earlier, one of the real strengths of SIT is its inherent fl exibility, struc- tured as it is around a cognitive foundation. SIT has been demonstrated to be of value in the control of anger, test anxiety, phobias, general stress, pain, surgical anxiety, essential hypertension, and PTSD (see Meichenbaum, 1985, 1993 and D’Arienzo, 2010 ) .
Acceptance and Commitment Therapy
In the past decade, there has been a fl ourishing of a “third wave” of psychotherapeutic models that focus on the relevance of distressing thoughts and emotions, and empha- size concepts such as mindfulness, acceptance, cognitive defusion, and spirituality in treatment (Hayes, 2004 ) . Acceptance and Commitment Therapy (ACT; Hayes, Strosahl, & Wilson, 1999 ) is one of the more prominent of these therapies. Although we appreciate that ACT is more closely aligned with the basic tenets of traditional cognitive-behavioral therapy (CBT) (Forman & Herbert, 2009 ) , the emergence of ACT, particularly its cognitive foundation warrants a brief review in this volume.
As noted by Hayes ( 2004 ) , “Theoretically speaking, ACT is rigorously behav- ioral, but yet is based on a comprehensive empirical analysis of human cognition”
(p. 640). More recently, Hayes and his colleagues describe that “ACT is an overarch- ing model of key intervention and change processes, linked to a research program on the nature of language and cognition, to a pragmatic philosophy of science, and to a model of how to speed scienti fi c development…a contextual behavioral science
(CBS) approach” (Hayes, Levin, Plumb-Vilardaga, Villatte, & Pistorello, 2011 , in press). ACT is based primarily on Relational Frame Theory (RFT; Hayes et al., 2011 ) , which adheres to the basic tenet that human language and cognition are based on how events are mutually combined and related to each other based on arbitrary cues not just on their formal properties, and grounded in functional contextualism that in essence “conceptualizes psychological events as a set of ongoing interactions between whole organisms and historically and situationally de fi ned contexts” (Hayes, 2004 p.646). In other words, ACT considers that actions are whole events and that their meaning is established only with consideration of the established contextual func- tion, relational frames, and meaning of an event both historically and situationally, and not just solely on its occurrence (Hayes et al., 2011 ) . This is thought to be one of the differences between ACT and traditional cognitive therapy, which is considered by ACT therapists to be more mechanistic (i.e., a bivariate causal chain or link between cognitions and behaviors that does not require an explanation of the cogni- tions’ origins) (Herbert & Forman, 2011 ) . In contrast, ACT therapists, while accept- ing the possible causal role of cognitions, assert that it is relevant to explore and examine external factors, including environmental and others that are manipulable, that serve as the origin of cognitions (Herbert & Forman, 2011 ) . More speci fi cally,
“thoughts may be related to particular emotional and overt behavioral events, but only in historical and situational contexts that give rise both to these thoughts and to their relation to subsequent emotions and actions” (in press).
According to Hayes and colleagues ( 2006, 2011 ) , there are six core processes or psychological skills associated with ACT interventions, including, (1) acceptance (actively embracing experiences in the moment without attempting to alter content or frequency); (2) cognitive defusion (changing one’s interaction or relation to cog- nitions by considering or creating other contexts that diminish their literal interpre- tive quality or unhelpfulness; taking thoughts literally without considering the process of thinking itself) (3) being present or in contact with the present moment (continual nonjudgmental and direct occurrences to allow actions to be consistent with held values), (4) self as context (being aware of one’s experiences without attachment to them, thus fostering acceptance); (5) values (clarifying goals and objectives in order to allow actions to produce these goals and the barriers that keep one from them); and (6) committed action (being focused on moving toward aspired goals, working through barriers, and having an action plan). According to the ACT perspective, distress or psychopathology is the result of taking cognitions literally and being focused on problem solving despite its questionable bene fi t. In general, this is referred to as “psychological in fl exibility” and the primary goal of ACT inter- vention is to become more fully aware of the here and now and applying the core processes through various exercises to increase fl exibility (Hayes et al., 2011 ) .
A 2009 meta-analysis of 18 randomized control studies of ACT with a total sample size of 917 participants (Powers, Zum V rde Sive V rding, & Emmelkamp, 2009 ) revealed overall that ACT was superior to control conditions (waiting list, treatment as usual, psychological placebo) with an effect size of 0.42. The results revealed that participants receiving ACT were more improved than 66% of participants in the con- trol condition, but ACT was not more effective than control conditions for distress