Ch. 18 Cognitive Therapy

selective abstraction

A _____ ______ (sometimes referred to as a mental filter) is a conclusion based on only a selected portion of the evidence. The selected portion is usually the negative evidence or what the individual views as a failure, rather than any successes that have occurred. ex: Jackie just graduated from high school with a 3.98/4.00 grade point average. She won a scholarship to the large state university near her home. She was active in sports and activities in high school and well-liked by her peers. However, she is very depressed and dwells on the fact that she did not earn a scholarship to a prestigious Ivy League college to which she had applied (instead of considering her many other accomplishments). While on a date, you say one thing you wish you could have said differently and now see the entire evening as a disaster. Harry just retired after 30 years in a very successful career as an architect. He worked for a large firm, led many projects, made a lot of money, and is financially comfortable in his retirement. "But I was never considered for partnership in the firm."

a (restate what the patient already said to help them develop insight, this will help them sort out their own thoughts)

A client reports to the nurse, "My wife left me. No one else will ever love me. I'm going to be alone for the rest of my life." Which action by the nurse reflects an appropriate, cognitive-focused response? a. "What contributes to your thinking that you will be alone for the rest of your life?" b. "You're just overgeneralizing." c. "Why did your wife leave you?" d. "I'm sure there are other people that love you."

b (use what they said and create a hypothesis to then examine the evidence that supports)

A client tells the therapist, "I thought I would just die when my husband told me he was leaving me. If I had been a better wife, he wouldn't have fallen in love with another woman. It's all my fault." The therapist wants to use the technique of "examining the evidence." Which of the following statements reflects this technique? a. "How do you think you could have been a better wife?" b. "Okay, you say it's all your fault. Let's discuss why it might be your fault, and then we will look at why it may not be." c. "Let's talk about what would make you a happier person." d. "Would you have wanted him to stay if he didn't really want to?"

b

A client who was admitted to teh psychiatric unit for depression tells the psychiatric nurse that he wants to engage in CBT after discharge. Which action by the nurse is most appropriate at this point? a. Offer to begin CBT with the patient while he is hospitalized. b. Offer to explore referral to a therapist for this kind of treatment. c. Educate the client that CBT can only be completed while he is hospitalized. d. Educate the client that CBT is not effective for treating depression.

a

A nurse is using decatastrophizing techniques to help a client modify automatic thoughts and schemas. Which nursing statement could be used in this process? a. "First you must decide if this negative thought is valid." b. "Let's really look at that thought pattern. What evidence made you come to that conclusion?" c. "When you start to have a negative thought, start visualizing a pleasant experience." d. "Let's explore some other possibilities related to this thinking."

a

A patient diagnosed with severe depression states, "When I wasn't invited to my niece's wedding, it was obvious that the in-laws did not think I was good enough to be included." The nurse understands that this automatic thought is an example of which common cognitive error? a. arbitrary inference b. overgeneralization (absolute thinking) c. dichotomous thinking d. personalization

c

A patient states, "I just failed my college English course. I've never failed a class before so when my parents find out they re going to disown me. They'll hate me and never forgive me for this." The nurse recognizes this patient's statement as which type of automatic thought? a. arbitrary inference b. minimization c. catastrophic thinking d. personalization

catastrophic thinking

Always thinking that the worst will occur without considering the possibility of more likely positive outcomes is considered _____ _____. "worst case scenario syndrome" ex: On Janet's first day in her executive assistant job, her boss asked her to write a letter to another firm and put it on his desk for his signature. She did so and left for lunch. When she returned, the letter was on her desk with a minor typographical error circled in red and a note from her boss to correct the letter. Janet thinks, "This is it! I will surely be fired now!" (without considering that this may simply be her boss's way of orienting her to the expectations of the job). Janet has been invited to apply for membership in an exclusive women's club in her town. She is very flattered whey they invite her to a luncheon at the country club. During lunch, she accidentally spills some water on the tablecloth. She is mortified, and thinks, "That's it. I will never be accepted now!" Boss sends email he wants to talk, and you automatically think you are going to be fired.

dichotomous thinking

An individual who is using _____ _____ views situations in terms of all-or-nothing, black-or-white, or good-or-bad. ex: Look at that guy frowning. They all hate me! "Looks to me like most of them are having a great time..." Frank submits an article to a nursing journal, and the editor returns it and asks Frank to rewrite parts of it. Frank thinks, "I'm a bad writer" (instead of recognizing that revision is a common part of the publication process). Carol is a nursing student. She has always made As in her prenursing classes. When she makes a B on her first nursing exam, she thinks, "I will never be a good nurse!"

reattribution

Modifying automatic thoughts and schemas: _____ is an example of a cognitive strategy. Aims to reverse self-blame or placing blame solely on others to a more balanced attribution of responsibility.

12-16

Cognitive behavior therapy is highly structured and short-term, typically lasting from _____-_____ weeks.

emotional

Cognitive therapy was originally developed for use with depression and is now used to treat a broad range of _____ disorders. These disorders include depression, panic disorder, generalized anxiety disorder, social phobia, obsessive-compulsive disorder, posttraumatic stress disorder, eating disorders, substance use disorders, personality disorders, schizophrenia, couple's problems, bipolar disorder, illness anxiety disorder, and somatic symptom disorder.

magnification

Exaggerating the negative significance of an event is known as _____. "blowing things out of proportion" ex: Nancy hears that her colleague at work is having a cocktail party over the weekend, and she is not invited. Nancy thinks, "She doesn't like me" (instead of considering that this may have been an event for a specific group of people). An employee believes that a minor mistake will lead to being fired. Nancy has kept in touch with Emma since their college days, but the letters are becoming less frequent, and Nancy hasn't heard from Emma for almost a year now. Nancy thinks, "She obviously doesn't think of me as a friend anymore."

arbitrary inference

In a type of thinking error known as _____ _____, the individual automatically comes to a conclusion about an incident without the facts to support it or even despite contradictory evidence. ex: A young woman with anorexia nervosa believes she is fat although she is dying from starvation. Jane has joined a duplicate bridge club. Last week she was assigned to play with Sara as her partner. When she arrives at the bridge club this week, Sara has already signed up to be partners with Linda. Jane thinks, "She didn't like playing with me. She thinks I'm a lousy bridge player!" Two months ago, Mrs. B. sent a wedding gift to the daughter of an old friend. She has not yet received acknowledgment of the gift. Mrs. B. thinks, "They obviously think I have poor taste" (instead of considering what other reasons there might be for a delay in the recipient's response). A patient diagnosed with severe depression states, "When I wasn't invited to my niece's wedding, it was obvious that the in-laws did not think I was good enough to be included."

behavioral interventions

It is believed that thoughts affect behavior and that behavior influences thoughts 4 procedures help the client learn adaptive behavioral strategies that have a positive effect on cognitions: 1. activity scheduling: Daily log of activities (hourly) and rate each activity (mastery & pleasure) on a 0-10 scale 2. Graded task assignments - When facing overwhelming situation - break tasks into subtasks - by doing this and completing subtasks it will increase self-esteem and decrease helplessness. 3. Distraction - engage in other activities to redirect thinking/divert fro intrusive thoughts or depressive ruminations. 4. miscellaneous techniques - Relaxation exercises, assertiveness training, role modeling, social skills training, and contingency management contracts

unlovability

Maladaptive/Negative: I'm stupid. No one would love me. I'm nobody without a man. Adaptive/Positive: I'm a lovable person. People respect me for myself.

examining options and alternatives

Modifying automatic thoughts and schemas: _____ _____ _____ _____ is an example of a cognitive strategy. Helping patient see broader range of alternative - patient learns to generate alternatives.

questioning the evidence

Modifying automatic thoughts and schemas: _____ _____ _____ is an example of a cognitive strategy. View the automatic thought as the hypothesis, and the client is assisted in questioning the facts associated with their cognitions.

cognitive rehearsal

Modifying automatic thoughts and schemas: _____ _____ is an example of a cognitive strategy. Mental imagery to uncover potential automatic thoughts in advance and identify new ways to modify.

decatastrophizing

Modifying automatic thoughts and schemas: _____ is an example of a cognitive strategy. "What's the worst thing that could happen?" & then develop action plan. Even if some validity exists, patient encouraged to review ways to cope and move beyond situation.

didactic (educational) aspects

Prepare patient to eventually become his/her own therapist The therapist provides information about cognitive behavior therapy and provides assignments to reinforce learning. A full explanation about the correlation between distorted thinking and clients' mental illness is provided.

1

Principal 1. Cognitive behavior therapy is based on an ever-evolving formulation of the patient and his or her problems in cognitive terms. The therapist identifies the event that precipitated the distorted cognition. Current thinking patterns that serve to maintain the problematic behaviors are reviewed. The therapist then hypothesizes about certain developmental events and enduring patterns of cognitive appraisal that may have predisposed the patient to specific emotional and behavioral responses.

10

Principle 10. Cognitive behavior therapy uses a variety of techniques to change thinking, mood, and behavior. Techniques from various therapies may be used within the cognitive framework. Emphasis in treatment is guided by the patient's particular disorder and directed toward modification of the dysfunctional cognitions that contribute to the maladaptive behavior associated with the disorder. Examples of disorders and the dysfunctional thinking for which cognitive therapy may be of benefit are discussed later in this chapter.

2

Principle 2. Cognitive behavior therapy requires a sound therapeutic alliance. A trusting relationship between therapist and patient must exist for cognitive therapy to succeed. The therapist must convey warmth, empathy, caring, and genuine positive regard. Development of a working relationship between therapist and patient is an individual process, and patients with various disorders will require varying degrees of effort to achieve this therapeutic alliance.

3

Principle 3. Cognitive behavior therapy emphasizes collaboration and active participation. Teamwork between therapist and patient is emphasized. They decide together what to work on during each session, how often they should meet, and what homework assignments should be completed between sessions.

4

Principle 4. Cognitive behavior therapy is goal-oriented and problem-focused. At the beginning of therapy, the patient is encouraged to identify what he or she perceives to be the problem or problems. With guidance from the therapist, goals are established as outcomes of therapy. Assistance in problem-solving is provided as required as the patient comes to recognize and correct distortions in thinking.

5

Principle 5. Cognitive behavior therapy initially emphasizes the present. Resolution of distressing situations that are based in the present usually leads to symptom reduction. It is therefore more beneficial to begin with current problems and delay shifting attention to the past until (1) the patient expresses a desire to do so, (2) the work on current problems produces little or no change, or (3) the therapist decides it is important to determine how dysfunctional ideas affecting the patient's current thinking originated.

6

Principle 6. Cognitive behavior therapy is educative, aims to teach the patient to be his or her own therapist, and emphasizes relapse prevention. From the beginning of therapy, the patient is taught about the nature and course of his or her disorder, about the cognitive model (i.e., how thoughts influence emotions and behavior), and about the process of cognitive therapy. The patient is taught how to set goals, plan behavioral change, and intervene on his or her own behalf.

7

Principle 7. Cognitive behavior therapy aims to be time-limited. Patients often are seen weekly for a couple of months, followed by a number of biweekly sessions, then possibly a few monthly sessions. Some patients want periodic "booster" sessions every few months.

8

Principle 8. Cognitive behavior therapy sessions are structured. Each session has a set structure that includes (1) reviewing the patient's week, (2) collaboratively setting the agenda for this session, (3) reviewing the previous week's session, (4) reviewing the previous week's homework, (5) discussing this week's agenda items, (6) establishing homework for next week, and (7) summarizing this week's session. This format focuses attention on important items to maximize the use of therapy time.

9

Principle 9. Cognitive behavior therapy teaches patients to identify, evaluate, and respond to their dysfunctional thoughts and beliefs. Through gentle questioning and review of data, the therapist helps the patient identify his or her dysfunctional thinking, evaluate the validity of the thoughts, and devise a plan of action. These tasks are accomplished by helping the patient examine evidence that supports or contradicts the accuracy of the thoughts rather than directly challenging or confronting the belief.

guided relaxation and behavioral rehearsal

Recognizing automatic thoughts and schemas: _____ _____ _____ _____ _____ is an example of a cognitive strategy. Increase awareness of conscious control over breathing, anxiety symptoms, and thoughts. Techniques may include deep breathing, imagery, mindfulness meditation, and other exercises. These techniques also increase awareness of conscious control over breathing, anxiety symptoms, and thoughts.

automatic thought records

Recognizing automatic thoughts and schemas: _____ _____ _____ is an example of a cognitive strategy. Written record of situations that occur and the automatic thoughts elicited by the situation. ex: a three-column journal that includes the situation, automatic thought, and emotional response Entry #1 Situation - My girlfriend broke up with me. Automatic thought - I'm a stupid person. No one would ever want tot marry me. Emotional response - sadness; depression Entry #2 Situation - I was turned down for a promotion Automatic thought - Stupid boss! He doesn't know how to manage people. It's not fair! Emotional response - anger

socratic dialogue

Recognizing automatic thoughts and schemas: _____ _____ is an example of a cognitive strategy. Patient is asked to describe feelings with specific scenario. The therapist questions the client to elaborate the "who, what, when, where, why, and how" of his or her situation. Restate patient's own words in a way that may stimulate insight into possible dysfunctional thinking and produce dissonance about validity of the thoughts.

cognitive

Relating to the mental processes of thinking and reasoning.

cognitive strategies

Strategies in CBT include recognizing and modifying automatic thoughts and recognizing and modifying schemas (core beliefs).

overgeneralization

Sweeping conclusions are _____ made on the basis of one incident—an "all-or-nothing" kind of thinking. ex: "Every time I'Ve been to Florida, the weather has been rainy. It's always raining in Florida!" "Since I overate at the last party I went to, I know I will overeat at every party I go to." "My mother, sister, and girlfriend diet all the time. Women are always on a diet!!" Frank submitted an article to a nursing journal, and it was rejected. Frank thinks, "No journal will ever be interested in anything I write." Janet thinks, "Not only will this club not want me, but no other club in town will want me now!"

appraisal

The model for cognitive therapy is based on an individual's cognition or an individual's personal cognitive _____ of an event and the resulting emotions or behaviors.

minimization

Undervaluing the positive significance of an event is called _____. ex: An alcoholic believes he/she doesn't have a problem. Alice has had two dates with Hank. She is very attracted to him. He must go out of town on business, but he told her he would take her out before he left. The day arrived for his departure, and she had not heard from him. She was very disappointed. He was out-of-town for a week and called her twice during that time. Nevertheless, Alice still felt betrayed by his not having taken her out before he left town. Mrs. M. is feeling lonely. She telephones her granddaughter Amy, who lives in a nearby town, and invites her to visit. Amy apologizes that she must go out of town on business and would not be able to visit at that time. While Amy is out of town, she calls Mrs. M. twice, but Mrs. M. still feels unloved by her granddaughter (instead of acknowledging the positive efforts of her granddaughter to keep in touch).

personalization

With _____, the person takes complete responsibility for situations without considering that other circumstances may have contributed to the outcome. "Don't take it personally.." ex: Jack, who is a car salesman, has just given a 2-hour demonstration to Mrs. W. At the end of the demonstration, Mrs. W tells Jack that she appreciates his demonstration, but she won't be purchasing a car from him. Jack thinks, "I'm a lousy salesman" (instead of considering that they may not have extra money to buy a new car at this time). The residents of a suburban neighborhood have been told that a possible escaped convict may be in their neighborhood and to not talk to or let any strangers in their homes. Sam is a college student walking door to door attempting to sell magazine subscriptions. No one will talk to him. He thinks, "I'm a lousy salesman. I'll never earn any money!"

schemas

____ are structures that contain the individual's fundamental beliefs and assumptions. Develop early in life from personal experience and identification with significant others These concepts are reinforced by further learning experiences and, in turn, influence the formation of beliefs, values, and attitudes. May be adaptive or maladaptive, general or specific, and positive or negative Schemas differ from automatic thoughts in that they are deeper cognitive structures that serve to screen information from the environment. For this reason, they are often more difficult to modify than automatic thoughts.

cognitive behavior therapy (CBT)

_____ _____ _____ is based on the cognitive model, which advances the concept that a person's perceptions/thoughts about a situation are more influential on his or her responses than the situation itself. Various techniques are incorporated to help clients learn how to change (reframe) their thinking and behavior in ways that will enhance mood, functioning, and sense of well-being.

automatic thoughts

_____ _____ are those that occur rapidly in response to a situation and without rational analysis. Often negative and based on erroneous logic Beck called these thoughts cognitive errors

cognitive therapy

_____ _____ is based on the theory that distorted cognitions are at the foundation of many emotional, mental, and behavioral disorders. Clients with depression often seem to be consumed by negative thoughts about themselves and about how others see them; clients with anxiety disorders often have worried thoughts about past and future events; clients with personality disorders often struggle with maladaptive thoughts about their relationships with others.

helplessness

_____ is the act of being unable to help oneself; lacking strength or power. Maladaptive/Negative: No matter what I do, I will fail. I must be perfect. If I make one mistake, I will lose everything. Adaptive/Positive: If I try and work very hard, I will succeed. I am not afraid of a challenge. If I make a mistake, I will try again. ex: "No matter what i do, I will fail."

three

_____ major components of cognitive behavior therapy 1. Didactic or educational aspects 2. Cognitive techniques 3. Behavioral interventions

Goals

_____ of cognitive behavior therapy The patient will: 1. Monitor his or her negative automatic thoughts. 2. Recognize the connections between cognition, emotions, and behavior. 3. Examine the evidence for and against distorted automatic thoughts. 4. Substitute more realistic interpretations for these biased cognitions. 5. Learn to identify and alter the dysfunctional beliefs that predispose him or her to distort experiences.

true

true or false: Nurses are able to implement cognitive behavior therapy techniques into their nursing practice. It is within the scope of nursing practice.