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Topic 12: Cognitive-Behavioral Interventions

Behavioral Interventions
Behavioral therapies assume that human problems result from learning maladaptive ways to
respond to the environment. There are four ways on how to learn these maladaptive ways. The
Classical Conditioning, the Operant/Instrumental Conditioning, the Observational Learning
and the Verbal Learning. For each of those learning types, there is a fitting type of therapy.

Exposure-Based Behavior Therapies

Exposure-Based Behavior Therapies are based on the 2 Factor Theory (O. Hobart Mowrer’s,
1950). This theory says that anxiety, dissociation or somatization symptoms are a result of
two factors. The classical conditioning: problems occur when a neutral stimulus is associated
with a noxious unconditioned stimulus to produce fear and anxiety. And instrumental
avoidance conditioning: avoidance of this feared cue is then reinforced by reductions in
classically conditioned anxiety.

Systematic Desensitization (Reciprocal Inhibition)

Exposure techniques are effective with different kinds of anxiety symptoms. There are several
exposure techniques for anxiety disorders. For example, the in vivo exposure is best for
simple phobias, the interoceptive exposure is best for fears associated with bodily sensations,
the virtual reality exposure for fears of heights, flying, driving, and spiders. The imaginal
exposure for situations where in vivo exposure is difficult to arrange. Additionally, to the
classical exposure techniques, there are relaxation techniques, which help the client with self-
soothing and emotional regulation as well as managing emotional distress. And the panic
control therapy to treat panic disorders.

Eye Movement Desensitization and Reprocessing (EMDR)

The EMDR is effective for treating posttraumatic stress disorder, phobias, grief and somatic
disorders. The bilateral neurophysiological stimulation of the brain with back-and-forth eye
movements desensitizes and reprograms trauma-related memories. The treatment involves
four procedures which continue sequentially during each of three 90–120 min sessions. First,
we have the assessment, followed by desensitization, installation and equilibrium.

Flooding and Implosive Therapies

Flooding and implosive therapies involve massed, intense evocations of feared cues, which
require a strong therapeutic alliance. The sessions are open-ended, they just stop when the
client no longer shows signs of anxiety. You can imagine that trust between the patient and
the therapist here is really important. The association between feared cues and anxiety should
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be extinguished. The flooding focuses on consciously expressed fears, while the implosive
therapy helps to confront hypothesized psychodynamic conflicts.

Acceptance or Mindfulness-Based Interventions

Acceptance or Mindfulness-Based Interventions help clients tolerate anxiety-inducing
thoughts or impulses. They encourage a full awareness of both inner and outer experiences.
While clients master the fear, avoidance gets eliminated and self-confidence gets higher.

Operant-Based Behavior Modification

Behavior modifiers suggest that abnormal, antisocial, or merely eccentric behaviors are
responses to environmental cues and reinforcers. Three operant principles are used to modify
problematic behavior: Control discriminative stimuli, Eliminate reinforcers (extinction) and
Countercondition responses incompatible with the problem behavior. Three other procedures
help modify complex behaviors: Shaping of complex behaviors by reinforcing
approximations, Chaining the components of complex behaviors and Reinforcement fading
which prevents extinction of new behaviors.

Behavioral Activation
Behavioral Activation is frequently used with depressed individuals. It encourages clients to
maximize intrinsically reinforcing activities or offer opportunities for social reinforcement.
Clients should write a diary. This records whether activities were planned or spontaneous,
rewarding or unpleasant, monotonous or interesting, or accompanied by ruminations. The
baseline is then compared against activities that used to be enjoyable, but now occur
infrequently. Clients also explore any activities that might be enjoyable but have never been
tried. These various lists are compared to determine which unpleasant activities might be
reduced and which pleasurable ones might be increased. Important here is to make sure that
the client is really doing his homework.

Cognitive Behavior Modification Approaches

Cognitive behavior modification includes related approaches that consider thoughts to be a
verbal behavior modifiable by exposure, operant, and modeling principles.

Psychoeducation and Social Skills Training

Psychoeducation and Social Skills Training helps teaching clients how to change behavior
and thoughts. Clients gain new perspectives as they provide each other feedback on their
skills.
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Social Learning Programs (SLPs)

SLPs combine psychoeducation and social learning with token economy programs to address
generalization and treatment adherence in institutional settings. The residents learn adaptive
social skills to replace deviant, bizarre, or aggressive behavior. And the staff receives ongoing
consultation and training to help create a positive social environment for the residents
Assertiveness Training
The assumption here is that everyone has the right to express their feelings in a respectful
manner. The ultimate goal of assertiveness training is to obtain the ability to choose whether
or not to be assertive about legitimate needs. There are also different sub-skills which clients
will obtain during the training. Skills such as desensitizing anxiety about assertiveness,
speaking in a louder voice, learning appropriate eye contact, learn how to use nonverbal
behavior and the use of I-language. Additionally, there are active listening skills to obtain.

Thought-Stopping
Thought- Stopping helps clients manage intrusive, ruminative thoughts, impulses, or images.
The clients learn to recall the thought and then yell “STOP!!!”

Problem-Solving
Problem-Solving was designed for clients with dependency or self-efficacy difficulties. The
first step evaluates any attributional biases that might interfere with effective problem-
solving. Biases such as minimizing, externalizing responsibility, internalizing responsibility,
global attributions and stable attributions.
Clients need to recognize how they use automatic attributions before beginning training in the
four stages of problem-solving:
1. Problem definition
2. Generate alternatives
3. Decision making
4. Solution implementation and verification

Stress Inoculation
Stress Inoculation helps teaching adults to anticipate, prevent, and solve problems by
following three steps:
1. Conceptualize the problem
2. Try on the conceptualization
3. Modify cognitions and produce new behaviors

Lazarus’ BASIC-ID Multimodal Therapy

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Lazarus’ BASIC-ID Multimodal Therapy is a framework that describes interventions for

different areas where problems can occur. Interventions for the following areas. Behavior,
affect, sensation, imagery, cognition, interpersonal relations, drugs/biology.

Cognitive Approaches
First, there is a separation between the modernist scientific epistemology of cognitive therapy
and its phenomenological constructivist assumptions about the ontology of change. On the
one hand, Albert Bandura (1965) recognizes that classical and operant conditioning models do
not explain behavior and that this was better addressed through phenomenological therapies.
And, on the other hand, Donal Meichenbaum (1977, 1992) illustrated the evolution of
cognitive therapy from its behavioural beginnings.
1.RATIONAL EMOTIONAL BEHAVIOUR THERAPY
The first cognitive approach has been called directive, rational-emotive and, more recently,
rational-emotive and cognitive-behavioral therapy (RECBT). Ellis suggests that while an
experience may be unpleasant, the emotional disturbance results from interpreting it as
terrible, horrible, or something that cannot be survived. RECBT therapists challenge the
client's "irrational" thoughts and assign tasks to practice behavior based on "rational"
thoughts.
2. CONCEPTUAL FRAMEWORK
In order to understand the conceptual framework we must understand the ABC of thought,
that is, A would be the preceding events that are evaluated; B belongs to the beliefs about the
meaning of the events and C, to the emotions or behaviors consequent to the responses to B.
The beliefs may be of 2 types, rations, which will give rise to adaptive and irrational
emotional and behavioural responses that will give rise to maladaptive emotional and
behavioural responses. Within the irrational beliefs 3 types are described:
1. I should perform well and earn the approval of others at all times. If you fail, you will be
considered an incompetent and unworthy person, who deserves to suffer.
2. Others should treat me well at all times, and if they do not, they are unworthy. If they
misbehave they should be punished.
3. Things must be safe, without problems, predictable and pleasant at all times, and if they are
not, everything will be horrible and unbearable, and therefore not worth living.
The common point of these beliefs is that they are absolute requirements. Wishes, preferences
and desires become absolute "needs" that cannot be questioned or denied. They are
emotionally draining, and interfere with learning.
They lead to vague, strange and boring communication that interferes with intimacy or
sexuality and creates interpersonal conflicts. RECBT encourages rational beliefs such as:
1. I have human limitations and defects, just like other people. I feel better when I am
dedicated to helping others, when I focus on self-respect and love rather than worrying about
being loved.
2. People sometimes behave in stupid, ignorant, or neurotic ways. They need my
understanding, not my censure.
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3. If conditions are bad or not the way I want them to be, maybe I can change them. I need to
remember that my desires, like sex, are preferences, not needs.
The goal is to help clients realize that they have control over destructive emotions. RECBT
encourages people to accept themselves as they are, rather than trying to live up to the
expectations of others. It focuses on the beliefs that sustain the problems. As the approach has
evolved, it has placed more emphasis on the biological components of emotions.

3.INTERVENTION TECHNIQUES
The therapists of the RECBT:
D. Dispute irrational beliefs when clients act in a self-destructive manner;
E. Develop effective new philosophies that result in new ones,
F. They take feelings into account.

Ellis considers the RECBT to be humanistic as it is based on the client's own beliefs. The
three Rs encourage clients to challenge their own irrational ideas:
Detect: recognize absolute and must disturbing thought as self-defeating.
Debate: ask for beliefs logically and empirically and reject those that are not supported by
reality.
Discriminate: after repeated discussions, clients recognize irrational ideas as they occur and
are unaffected by them.

Ellis (1999) suggests that there is a philosophical restructuring of beliefs as clients learn:
1. They are largely responsible for creating their own emotional problems;
2. They have the capacity to change these disturbances in a significant way;
3. That emotional problems are largely the result of irrational ideas;
4. To clearly perceive how their beliefs are irrational
5. 5. To value the dispute of such beliefs;
6. To work hard to counter dysfunctional beliefs with painful consequences; and
7. To continue to address dysfunctional attitudes, behaviors, and consequences throughout life

A psychoeducational perspective is favoured over an intense therapist-client transference

relationship. Therapists are expert trainers who help clients understand how:
1. They have incorporated irrational duties and responsibilities into their thinking;
2. They keep the emotional disturbance alive by indoctrinating themselves with irrational
ideas;
3. Discuss and abandon their irrational ideas and modify their thinking; and
4. To develop a new, more rational philosophy.

Ellis (1999) uses humor and logical analysis to illustrate how irrationality causes emotional
and behavioral disturbances. Clients are taught to observe and apply the scientific method in
their thinking to minimize irrational ideas and illogical deductions. Emotional techniques
include unconditional acceptance, energetic and vigorous intervention, modeling and role-
playing, and exercises that attack the client's self-evaluation or shame. RECBT practitioners
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also freely borrow behavioral techniques as needed, including self-control, contingency

management, exposure techniques, relaxation, and real-life tasks

4.COGNITIVE THERAPY
Aaron Beck's Cognitive Therapy (CT) is perhaps the most influential cognitive approach. Its
approach is directive, active, structured, present-centered, and time-limited. CT also
emphasizes recognizing and changing maladaptive thoughts and beliefs, but Beck focuses
more on internalized representations or cognitive schemas of the self, the world, and the
future: the cognitive triad.
The assumptions of TC (Reinecke & Freeman, 2003) include
1. How people interpret events affects how they feel and behave.
2. The construction is active and continuous
3. Belief systems give personal and idiosyncratic meaning to events and selectively bias
memory and what is perceived or overlooked
4. Events interpreted as stressful activate maladaptive and over-learning coping responses that
"feed" into and reinforce the belief system or cognitive schema and keep the stress
interpreted.
5. Cognitive specificity hypothesizes that the specific content of maladaptive cognitive
schemas explains the differences between clinical disorders and emotional states.
6. Introspection allows access to the inner experience, dialogue and assumptions of a
cognitive schema.

CT assumes that cognitive schemas or belief and meaning systems determine behavior.
Cognitive schemas involve perceptions, memories, expectations, values, emotions, goals, and
our action plans, whether conscious or not.

5.CONCEPTUAL FRAMEWORK
Beck (1963) originally suggested that depression reflects a cognitive triad of distorted,
negative schemas about the self, the world, and the future. Individuals see themselves as
defective and unable to meet their needs, others as rejected and indifferent, and the future as
bleak.
Different anxiety disorders are believed to reflect different types of threat, while personality
disorders are believed to reflect still other specific contents and processes involving the
cognitive triad.

5.1. DIAGRAMS
Schemes are widespread expectations about the self in relation to others and the world. They
encompass neural networks that constitute memories and emotions, these networks are
activated when goal-related events occur.
When the perception of experiences is incongruent, it is ignored, while when it is congruent, a
pattern is formed, which stabilizes the experience. In terms of adaptation, when a pattern is
too incongruent with current experience to be assimilated, it gives rise to new patterns.
Cognitive therapy exposes clients to incongruent experiences or uses non-critical care (Baer,
2003) to modify schemas and minimize their biased influence on current experience.
Cognitive therapists view learning as an epigenetic "evolution of meaning" in which new
experiences build upon and modify existing cognitive schemas (Kegan, 1982).
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5.2. COGNITIVE DISTORTIONS

Maladaptive patterns reflect an evolution of relationships that may have been adapted during
childhood, but may now create difficulties. Such patterns can give rise to automatic thoughts
that people apply without questioning their validity.
Automatic thoughts are considered unproven, rather than irrational, they:
1. Hold rigid, negative beliefs about self-esteem and overestimate the results that make them
vulnerable to depression;
2. Become depressed when social or environmental factors prevent them from valuing results;
3.They believe they are unloved and/or helpless;
4. They respond to stress or personal loss with these beliefs;
5. Either they have a sociotropic personality style in which the loss of valuable relationships
indicates lack of personal worth, or an autonomous personality style in which failure to
achieve valuable goals indicates lack of personal worth.
In general, there is good support for the importance of cognitive distortions that mediate
human problems.

6. COGNITIVE-BEHAVIORAL INTERVENTION
Tang and Beck (2001) suggest that behavioral activation and self-managed reward
contingencies can increase the activity levels of depressed clients and enhance their sense of
self-efficacy and pleasure in daily activities. In self-management, clients keep diaries that rate
the moods associated with their activities. Journals help therapists understand how clients
spend their time and provide baselines for evaluating outcomes.
Therapists help clients anticipate and overcome obstacles or barriers to programming, or
review programming if necessary. If a client has negative thoughts about an activity, then
empirical tests of its validity are scheduled. Complex and difficult tasks are broken down into
sub-objectives, or graded so that the easier tasks are attempted first. If clients do not complete
the task, then the reasons for non-compliance are explored. If non-compliance reflects past
failures of the client, then associated negative beliefs, thoughts, or situational obstacles can be
discussed using cognitive therapy.

6.1. COGNITIVE THERAPY

Establishing a collaborative and trusting relationship with the client is essential to this,
therapists create a sense of discovery while guiding the exploration of the origins of beliefs
and the meaning of traumatic events. A close and warm relationship is needed to explore
''transference'' reactions when clients with chronic disorders try to avoid exploring unexpected
changes, saying that it is not important.
A basic principle of TC is to explore all automatic thoughts and reactions, including those
activated by the therapeutic relationship. Beck and Freeman (1990) suggest that
noncollaboration is often a problem of motivation or ability rather than "negative
transference" or "resistance. Problems in therapeutic collaboration may be due to external or
therapist factors as well as to client issues.
When a lack of collaboration occurs, therapists should first examine their own contribution. If
the therapist and external factors are not the problem, then the non-cooperation probably
reflects dysfunctional beliefs of the client that are a necessary starting point for the CT scan.
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The Dysfunctional Thinking Record (DTR) is used to identify automatic thoughts either alone
or in conjunction with a behavior diary. Once clients reliably report situations, thoughts, and
feelings, the therapist helps them examine the validity of their automatic thoughts.
Therapists use the ratings to assess how the questioning impacts the automatic thoughts. If
there is little impact, something has been overlooked and the client's belief has not been
successfully challenged.

6.2. EXPLORING AUTOMATIC THINKING

Initially, clients are prone to present "superficial" beliefs connected only vaguely to the
central schemes. Therapists first assess the core beliefs.
The downward arrow technique helps clients move from the derived beliefs and discover the
underlying core meanings. If a client says, "I know you think I'm a little mouse," the
downward arrow question would be, "If that were true, what would it mean to you?" If the
client answers, "He'll never want to marry me," the therapist could use the arrow again: "And
if he doesn't marry you, what would that mean?" If the client answers, "I'm so unloved, no one
will ever love me," this is closer to a basic schema and the therapist can question the
evidence, alternatives, and implications of the belief.
As the core beliefs are explored, cognitive distortions are likely to be discovered. The
Dysfunctional Attitude Scale (Weissman & Beck, 1978) can identify dysfunctional core
schemas. It has nine factors that, except for factor 8, reflect cognitive distortions that require
further exploration:
1. Vulnerability: "Whenever I take risks, I'm only looking for trouble."
2. Approval: "My value as a person depends on what others think of me".
3. Perfectionism: "My life is wasted if I don't succeed.
4. Need to please: "It is better to give up my interests to please other people."
5. Imperatives: "I should be happy all the time.
6. Needs to impress: "I must try to impress people if I want them to like me.
7. Avoiding weakness: "If a person asks for help, it is a sign of weakness.
8. Control of emotions: "Criticism doesn't have to bother the person who receives it.
9. Disapproval: "It is horrible to be disapproved of by people who are important to you.
Cognitive therapists use Socratic questioning of problematic cognitive distortions to help
clients discover answers for themselves. Categories of Socratic questions include:
1. Clarify: "What exactly did you mean by that last statement?
2. Assumptions: "Why do you think this happened? Can you explain your reasoning?
3. Perspective: "What else could explain this?
4. Evidence: "How do you know? How could you prove that idea?"
5. Implications: "What would happen next? How does that affect your partner?"
6. Meta-questions: "Why do you think I asked that question?"

Therapists avoid suggesting a particular meaning, but rather help clients discover the basic
meanings and patterns for themselves. This feature maximizes therapeutic collaboration in
exploring problems, generating solutions, and is useful for resilient clients.

7. CASE FORMULATION IN COGNITIVE THERAPY

After collecting demographic data, therapists work with clients to develop a problem list of
current difficulties in concrete and operational terms. The list is kept between five and eight
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items. The problems are specified quantitatively in terms of frequency, intensity and duration.
Socratic questions and the downward arrow help clients discover the underlying fundamental
beliefs. Historical factors that explain the origins of the core dysfunctional beliefs can also be
included. The treatment plan is then derived from the case formulation with concrete and
measurable treatment goals and sub-goals derived from the problem list. Interventions should
flow logically from the working hypothesis, focus on behavioral or cognitive changes (both if
needed), and address barriers to treatment.

8.SCHEME THERAPY
Although CT is effective for clients with acute symptoms, more characteristic and thematic
problems have not responded well to traditional cognitive-behavioral therapy. Recognizing
these limitations, Beck and his associates (Beck & Beck, 2005; Beck & Freeman, 1990) have
updated the CT approach to address thematic issues. Unlike CT, schema therapy emphasizes
the origins of maladaptive behavior in terms of attachment theory (Bowlby, 1973, 1982),
which involves the unresponsive care of an infant's safety needs. These early maladaptive
patterns avoid conscious verbal processing with rapid and automatic emotional responses that
are less likely to be modified by conscious verbal methods.

9. CONCEPTUAL FRAMING
Scheme therapy assumes that the therapy will be long-term and explores the childlike origins
of the client's maladaptive interpersonal schemes. Early maladaptive patterns are defined as
memories, emotions, cognitions, and body sensations related to generalized and dysfunctional
patterns of self and other relationships developed during childhood or adolescence (Young et
al., 2003).
These patterns reflect a child's unmet basic needs for secure attachment, autonomy, play and
spontaneity, freedom to express needs or feelings, and realistic limits and self-control.
Because this response occurs before conscious awareness, schema therapy uses experimental
methods to complement traditional CT interventions.

9.1. SCHEME DOMAINS

Factorial analysis suggests that the 18 maladaptive schemas of schema therapy can be
grouped into five domains (Schmidt, Joiner, Young & Telch, 1995):
1.Disconnect/Reject. These clients fear that their needs for safety, care and love will not be
met. This leads to one or more of the following patterns: abandonment, distrust, emotional
deprivation (coldness), impairment, alienation.
2. Impaired autonomy/performance. These clients find it difficult to differentiate
themselves from their family of origin and to function independently in the world. This leads
to: dependency/incompetence-passive and powerlessness in handling daily responsibilities,
vulnerability to harm/illness-catastrophic fears (medical, going crazy, accidents or crime),
undeveloped enmity/merger with other important people, lack of personal direction and
failure.
3. Limits of impairment. These clients lack self-discipline and respect for the rights of
others. They may be selfish, irresponsible, or narcissistic. This leads to: high expectations of
special privileges and insufficient self-control/self-discipline
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4.Other address. These clients prioritize the needs of others to gain approval, maintain
emotional connection, or avoid retaliation. They are not aware of their own needs and
feelings. This leads to: needs or feelings of suppression of subjugation for fear of retaliation,
anger or abandonment, self-sacrifice focusing on the needs of others who are seen as suffering
or more needy, and seeking approval/recognition (concern for status and appearances).
5. Oversight/inhibition. These clients were taught that life is dangerous and that one must be
alert and self-controlled to prevent a disaster from occurring. This leads to:
negativity/pessimism, emotional inhibition, unrelenting norms/hypercriticism and punitivism.

For any combination of schemes, clients can use any of three coping responses: surrender,
avoidance and overcompensation.

Young and others (2003) suggest that "each patient is considered to have a unique profile,
including various coping patterns and responses, each present at different levels of strength ‘’.
While patterns tend to be stable and difficult to change, coping responses are highly variable.
This may explain the problems of comorbidity and reliability in DSMIV Axis II diagnoses
(Young & Gluhoski, 1996).

9.2. OUTLINE MODES

While the patterns are relatively durable, the modalities of the patterns are "moment-to-
moment emotional states and coping responses - adaptive and maladaptive" (Young et al.,
2003, p. 37). As life events unfold, people move from one schema mode to another with
simultaneous changes in affect. There are ten schema modes, grouped into four categories:
child, dysfunctional coping, dysfunctional parent, and healthy adult mode.
Scheme therapy helps the healthy adult mode to regulate the dysfunctional modes.
Dysfunctional schema modes are dissociated self states that are not fully integrated into a
coherent self. Degrees of dissociation vary from fully integrated and conscious functioning to
fully dissociated functioning in dissociative identity disorders. Modes also differ in the degree
to which they are mild or extreme, rigid or flexible, and pure or a mixture of several modes.

10. INTERVENTION IN SCHEMA THERAPY

Scheme therapy is divided into two phases: 1. assessment and education, and 2. change.
During assessment and education, clients learn to identify patterns and recognize how coping
styles perpetuate patterns. During the change phase, a mix of cognitive, experiential,
behavioral, and interpersonal strategies help clients break this cycle of pattern perpetuation.

10.1. EVALUATION AND EDUCATION PHASE OF THE SCHEME

The objective of the assessment phase is to develop a conceptualization of the case on how
early maladaptation schemes and coping styles developed from dysfunctional interpersonal
experiences of childhood and adolescence. The assessment begins by deciding whether
schema therapy is appropriate for the client.
The assessment includes a focused life history that tracks the current problem over time to the
extent possible. Hypotheses about coping patterns and styles are developed in collaboration
with the client, based on repeated patterns of triggering events, thoughts, feelings, and actions
or symptoms. Family history, parenting style, relationships with significant others, traumatic
events, and possible biomedical or temperamental factors are explored for their role in
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developing coping patterns and responses. As clients relate to the therapist, the activation of
coping patterns will most likely produce strong feelings towards the therapist and influence
the quality of the relationship. When this occurs, the therapist asks the client to remember
other relationships that have created similar feelings and outcomes.
Targeted Imagery is an experimental technique used by schema therapists in both the
assessment and change phases. The images can help to identify the triggers of the schema,
link the schema to the problems that occur, and help the client experience the emotions related
to the schema.
Therapists help clients to examine their images to identify the origins of the childhood
schemas and relate them to current problems. While diagnosis provides clues about the
patterns, it is important to remember that almost any pattern can lead to almost any diagnosis.
Similar childhood experiences can create very different patterns or modify earlier patterns,
depending on other significant relationships. It is essential to identify the patterns accurately,
as very different therapeutic strategies may be needed for different patterns.

10.2. THE CHANGEOVER PHASE

The goals of the change phase of schema therapy include bonding, emotional regulation,
schema shift and autonomy. Four principles of change are important: the relationship of
therapy, cognitive restructuring and education, experimental imagery and dialogue work and
breaking the pattern of behaviour.

THE THERAPY RELATIONSHIP

After establishing a relationship and identifying patterns during assessment, therapists use
empathic confrontation, which helps clients recognize and modify how their patterns
influence the therapeutic relationship.
The therapist's reactions are an important resource for both scheme evaluation and change.
Therapists must recognize when their reactions are appropriate and when they reflect the
therapist's own patterns.
Therapist frameworks can be problematic in a number of ways:
1. The client's schema activates the therapist's schema
2. The therapist's schemes prevent answers to the client's needs
3. Therapists over-identify with clients who have similar patterns
4. The client's emotions trigger the therapist's avoidance
5. The client's schemes lead to overcompensation by the therapist
6. Clients are used to meet the needs of the therapist

Therapists must balance empathy and confrontation, which is essential when the therapy itself
triggers a pattern. Therapists first ask open-ended questions to get the client's feelings and
point of view, then validate the client's feelings as understandable and apologize if anything
hurtful was said or done. Once clients feel understood, therapists can self-reveal their own
reactions and perceptions.
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Limited reparation appropriately meets clients' needs for nurturing, autonomy, boundaries, or
self-expression. Reparation is "limited" in the sense that therapists provide temporary support
so that clients can safely cope with the painful history of a maladaptive scheme.
Repentance needs differ depending on the type of scheme. In general, therapists must meet
the attachment and nurturing needs of clients with schemas in the disconnect/rejection
domain. Therapists model appropriate self-control and discipline, set limits, and support
clients as they become more self-directed and emotionally connected. Therapists are non-
directive, but reinforce clients as they act independently and assert themselves. Therapists
model optimistic spontaneity, acceptance of self and others, and a balance of internal and
external norms. Play is modelled, encouraged and reinforced.

COGNITIVE STRATEGIES
Scheme therapy resembles Beck's cognitive approach (Beck & Freeman, 1990) by
emphasizing the active role of the therapist. Both approaches use cognitive and behavioral
strategies to help clients test schemas and cognitions against reality.
However, schema therapy begins with the core schemas and then links them to superficial
level thoughts, rather than Beck's top-down approach that moves from automatic thoughts to
basic beliefs. More time is spent identifying schemas, modes and styles of coping, and less
time is spent testing the validity of superficial beliefs. As a result, schema therapy is less
structured than Beck's cognitive approach and more likely to move between past and present
or from one schema to another. Another important difference is the degree of emphasis on
experimental images.
The goal of cognitive intervention is to strengthen the "healthy adult" mode so that clients can
challenge maladaptive patterns. Therapists align with the client by using empathic
confrontation to examine the evidence for a scheme and consider alternative explanations.
Experimental strategies are needed to alter feelings. One of the experimental strategies is the
reintroduction of images into the change phase after clients become adept at challenging the
schematics with memory cards. Imaginative dialogues with other important people in the
present and from childhood help clients express their anger about unmet needs. Outline mode
imagery work allows a "healthy adult" to support the "vulnerable child" whose needs were not
met by a "dysfunctional parent.
As clients distance themselves from the schematics, they may begin to grieve over inadequate
parenting. They begin to repair themselves, develop more realistic expectations for the future,
and accept the past.

THE BREAKDOWN OF BEHAVIOURAL PATTERNS

Breaking patterns of behavior helps prevent relapse once clients learn how the patterns affect
their lives and have begun to challenge them through the images. During this final phase of
schema therapy, behavioral techniques target self-destructive coping styles.
Therapists and clients collaborate to identify problematic sequences of self-destructive
behavior and their triggers, and review initial case conceptualizations with information
gathered during previous sessions. They then address motivation for change and prioritize
goals by linking problem behaviors to childhood origins and reviewing the pros and cons of
their continuance. The goal is to help clients forgive rather than blame themselves for
problems.
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10.3. WORKING MODE OF THE SCHEME

This unique intervention was developed after other techniques failed to help severely
disturbed narcissistic and borderline clients. It is now used with any client, such as self-
punitive or self-critical clients. There are seven steps to the schematic mode of working:
1. Identify and label the client's modes
2. Clients are helped to understand and empathize in a way once they discover their role in
childhood.
3. Linking maladaptive modes to current problems and symptoms
4. Demonstrate the benefits of modifying a mode when it interferes with another mode
5. Images are especially useful in the suppressed modes of vulnerable children
6. Therapists model a healthy adult mode that nurtures, protects, sets limits for the vulnerable
child mode
7. Help the client to generalize the way of working to situations of the outside life

11.MAIN POINTS
- Cognitive therapies bridge modernist and phenomenological approaches by suggesting that
people respond to beliefs, rather than to events themselves, and that therapy can use verbal
reports of those beliefs to examine how thoughts affect behavior. This has led to an evidence-
based integrative therapy: cognitive-behavioral therapy in its various forms.
- The ABCs of RECBT propose that Background events be interpreted according to the
individual's Beliefs, which then determine the Consequences of the event.
- Adaptive behavior results from rational beliefs that produce positive consequences, while
maladaptive behavior results from irrational beliefs that produce negative consequences.
- Treatment involves RECBT DEFs: Therapists challenge irrational beliefs; as clients are
persuaded to reject their irrational beliefs
- Clients are taught to detect, discuss and discriminate against irrational ideas until they no
longer lead to maladaptive responses. The therapist serves as an expert coach to help clients
see how irrational ideas keep emotional disturbances alive, discuss these ideas, and develop a
more effective philosophy.
- Cognitive therapy is active, collaborative, structured, present-focused, and time-limited. It
uses Socratic questions to challenge dysfunctional ideas rather than persuasion. It also focuses
on modifying the central patterns underlying dysfunctional thoughts, rather than modifying
superficial ones.
- Schemes are internalized representations of cognitive, affective, intentional and action
tendencies associated with a person's developmental experiences. The cognitive triad refers to
schemas that reflect the individual's beliefs about the self, the world, and the future.
- The cognitive specificity hypothesis holds that different diagnostic groups have specific sets
of beliefs regarding the cognitive triad. Depressed individuals have negative perceptions in all
three areas; they see themselves as defective, others as rejected and indifferent, and the future
as bleak. In contrast, anxious individuals perceive themselves as not competent to cope with a
threatening world.
- The patterns of maladjustment reflect an understanding of the world that may have been
accurate when first formed in childhood, but is no longer adaptable in an adult world. Some
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cognitive distortions associated with such patterns are dichotomous thinking, excessive
generalization, expansion or reduction, personalization, emotional reasoning and catastrophe.
- Schemes tend to assimilate new information into existing structures, rather than changing or
creating new schemes to accommodate incongruent information. This causes an assimilation
bias. Thoughts that result from assimilation bias without being proven accurate or useful are
called automatic thoughts.
- Cognitive distortions are monitored with the Dysfunctional Thought Record (DTR), which
is also used to identify precipitating events and challenge resulting thoughts.
- The downward arrow is used to move from superficial thoughts to central dysfunctional
patterns.
- Once automatic thoughts are described in terms of the central schema, Socratic questioning
explores three areas: "What is the evidence for and against this belief," "What alternative
explanations exist for the event," "What are the implications of your belief, if it is correct?
- Cognitive therapy treatment plans begin with a list of problems that suggest goals. They
identify core dysfunctional beliefs and situations that precipitate the client's problems. Then,
the case conceptualization suggests useful interventions and possible barriers to treatment.
- Outline therapy addresses long-standing and treatment-resistant thematic problems. It
focuses on issues of childhood attachment that create patterns of early maladjustment that are
not in consciousness and are not easily addressed by Socratic questioning.
- Five domains of early maladaptation patterns have been identified:
Disconnect/Reject; Impaired Autonomy and Performance; Impaired Limits; Other
Direction; Overwatch and Inhibition.
While maladaptation schemes are relatively stable, clients respond to them with one or more
relatively unstable coping styles: Surrender, avoidance or overcompensation.
- In the assessment and education phase, clients are helped to identify and re-experience
dysfunctional life patterns related to coping patterns and styles.
- The change phase challenges maladaptive patterns and uses a variety of interventions to
explore more adaptive ways of coping:
+Relational: repeated empathic confrontation of schema-driven patterns when they occur
outside of therapy and in the relationship allows clients to explore how to cope more healthily
+Cognitive: The task of exploring new ways of acting includes cards to summarize coping
patterns and styles and diaries of patterns.
+Experimental: Imagination enables clients to confidently re-experience past and present
problem relationships and to imagine alternative ways of responding.
+Behavioral: Pattern-breaking points to dysfunctional coping styles
- The modalities of the schemes reflect four categories of coping in each moment: child
(vulnerable, angry, impulsive, undisciplined or happy), dysfunctional coping (obedient
surrender, detached protector or overcompensator), dysfunctional parent (punitive or
demanding) and healthy adult modalities.
- The contributions of cognitive therapy toward therapeutic integration include:
1. Closing the gap between scientific modernism and phenomenology
2. Develop structured methods to modify dysfunctional thinking
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3. Integrate cognitive and behavioural methods

4. Expand the concept of a scheme to emphasize the influence of attachment experiences in
early childhood
5. Closing the gap with other approaches with Piaget's development concepts
6. A greater emphasis on the therapeutic relationship

Insight
Insight should be defined independently from the techniques that foster it. Many people
confuse the definition of insight with a restricted number of techniques or processes that may
foster it (e.g., client's free association, therapist interpretations). It should also be defined by
using a jargon-free vernacular, as opposed to a set of terms tied to a particular theoretical
orientation

Brief Historical Perspective

Insight was avoided because it related to uncounscious processes. For Bandura (1969), insight
or awareness were seen as phenomena of "social conversion," in which the client learns and
adopts the therapist's point of view, which poses ethical problems. Shoben (1960) argued that
insight was a possible countributor to recovery, but conditioing was still necessary. Cautela
(1965) refered to insight like events in desensitization training. They arose spontaneously
when the process was becoming effective (were seen as epiphenomenal and not causal
agents).

Cognitive perspective paved the way for insight.

Cognition (ideas, beliefs and assumptions) mediated conditioning and, therefore, the
relationship between stimuli and behavioral reactions. So, insight (cognition) could directly
lead to therapeutic change. Albert Ellis made a distinction between intelectual and emotional
insights (rational-emotive therapy), that was important and new. Beck (1976) centered on the
process of cognitive change: becoming aware of thoughts, recognizing which ones are
inaccurate, and substituting for more accurate thoughts. Insight is centered on recognizing the
irrationality of some thoughts and replacing them with alternative cognitions. Mahoney
referred to the process of belief modification as happening in an incremental way or by a
"cognitive click". Meichenbaum proposed that cognitive restructiring was a central concept
for behaviour change. It represents a schema change. Goldried and Davidson (1976) argued
that insight as a vehicle of change was incompatible with a behavioural model, but they
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aknowledged that it happened in a clinical setting and produced behavioral changes. Although
traditionally insight is not related with CBT, in reality it's a central process of change in this
orientation.

A Schema Focused View of Insight

This view proposes insight as a change of schemas (knowledge structures of self and others).
Changes in schemas involve different levels of mental representation. Change is accompanied
by emotional activation. It's not a departure from CBT tradition, its a learning process
consistent with other CBT constructs.

What are schemas?

They are mental representations in long-term memory or as a "cognitive representation of
individuals, past experiences with other people, situations, and themselves, which helps them
to construe events within that particular aspect of their life" (Goldfried, 2003, p. 56). On a
biological level they are neuronal groups. As do all forms of knowledge, schemas reflect
networks of connections, which are stored in different memory systems. Schemas influence
the enconding and retrieval of information, so they regulate what kind of information reaches
awareness. Self-schemas are "cognitive generalizations about the self, derived from past
experience, that organize and guide the processing of the self-related information contained in
an individual's social experience" (Markus, 1977, p. 63). This process of retrieval and
encoding makes the world seem coherent and organized. Safran (1990) argued that our views
of self are connected with the way we perceive others and our relationship with them. The
schemas are linked with attachment figures, allowing the person to maintain relatedness with
these figures. A change in self-schemas reflect a new understading of who the person is, a
new comprehension of relationships with others. This makes this concept fit in the CBT
oriented definition of insight.

How does insight vary?

Insight can vary in depth and have different levels of representation. Not all self-schemas are
acessible to awareness. They are related with different forms of psychological functioning and
memory systems (implicit and explicit). Schemas in explicit mode are voluntaraly acessible to
consciousness, in implicit mode they are non-conscious and only accessible via situational
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stimuli.

Insight and emotion

The central question is if emotion is if it’s necessary for insights lead to change. Tradionally
CBT views emotion as a phenomenon to be controlled rather than experienced or deepened,
but new multidimensional views of emotion allow a schema-focused view of insight. Teasdale
(1993) proposed that implicit meanings are directly linked to emotion and explicit aren't, so
they cannot elicit emotion (holistic idea of thinking with the heart and thinking with the head).
Safran (1989) proposed that insight needs to integrate the two modes of functioning (explicit
and implicit) to facilitate change. Perceptual and conceptual thought. Most powerful insights
integrate perceptual and conceptual thoughts. Safran (1990) said that "some aspects of an
individual's interpersonal schemas may be readily accessible in conceptual/linguistic form,
other aspects may be more difficult to access symbolically" (p. 94). Emotion, in this sense,
facilitates the transformation of a previously implicit memory into an explicit one. In this
sense, some emotional experiences are linked to core views of self, and acessing those
emotions can trigger past memories and associated meanings.

The authors of the chapters hypothesize that emotion is not absolutely necessary to produce
change. Representational level insight is also helpful. They also refer tot he importance of joy
as an emotion that appears when after an insight experience. It happens because insight solves
or gives the promise of solving an emotional problem (negative reinforcement) and others
lead to better opportunities (positive reinforcement). Also, the intensity of joy is a function of
the degree of the problem, the degree of percevei solutions or the degree of perceived
opportunities.

Insight Experiences as Learning

Within CBT theory, change can be conceived as learning. Grawe (2004) argued that
corrective experiences can be generated by triggering the schemas underlying the patient's
problematic experiences and behavior and then by overlaying them with new schemas. Grawe
(1997) identified two types of corrective experiences: clarification of meaning (cause and
effect connections) and mastering/copying. Schema change is not sufficient for insight: the
perspective shift needs to be consciously experienced and verbalized. It requires counscious
awareness of self-schemas. Essentially, insight is a learning process (a corrective experience
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of clarification) in which one consciously perceives connections between two or more mental
representations (schemas) that one had not previously viewed as connected or connected in a
particular way. The difference between insight and awareness is that the first referers to
schematic change and the later to just schema activation.

Empirical and clinical observations

Insight has five different dimensions: (1) object: the target of the new understanding; (2)
complexity: the number of connections involved in a new understanding; (3) representation:
level of explicitdness of the object previous to the insight. (4) intensity: level of emotions
associated with the insight. (5) acceleration: the degree of suddenness.

Empirical studies that validate ocurrence of insight in CBT

Clarke, Rees and Hardy (2004), through analizyng post-therapy interviews using grounded-
theory, found that insight occurs in CBT therapy. Gershefski, Arnkoff, Glass, and Elkin
(1996) found no differences on insight between different schools of psychotherapy. Other
studies (Llewelyn, Elliott, Shapiro, Hardy, and Firth-Cozens, 1988) show that insight occurs
more in psychodynamic therapy.
Are there CBT Specific Insights?
Elliott et al. (1994) compared insight events of three clients in CBT with insight events of
three clients in psychodynamic-interpersonal therapy and concluded that "it is thus important
not to assume that insight is the same in the two treatments" (p. 460).

Is Insight Beneficial in CBT?

In Cadbury, Childs-Clark, and Sandhu (1990) examination of CBT in anxiety, 36% said that
insight was one of the most helpful aspects (altough none did in marital therapy). Data also
suggests that the relation between outcome and insight is very dependent on the types of
outcome used. Data also shows mixed results.

One Final Note

One of the most important questions is the whether insight is causal or epihenomenal. The
authors defend that is causal in some cases and epiphenomenal in others.