Aaron Beck has defined CT as being an active, directive, time-limited, structured approach to therapy based in the underlying theoretical rationale that an individual’s affect and behavior are largely determined by the way in which one structures their worldview. The overall strategy of cognitive therapy emphasizes the empirical investigation of the client’s automatic thoughts, inferences, conclusions, and assumptions. Thoughts (cognitions) either verbal or pictorial are based on the attitudes or assumptions (schemas), developed from previous life experiences. For example, a client may develop schema that says, “I cannot relate socially unless I have a drink to calm me down.” Consequently the client reacts to situations in terms of inadequacy even when they are unrelated to whether or not one is personally competent. Beck believes the therapeutic techniques of CBT are designed to identify, reality-test, and correct distorted conceptualizations and the dysfunctional beliefs or schemas which underlie the negative thoughts. The client learns to master problems and situations, which were previously considered impossible to successfully negotiate by reassessing and then correcting their cognitions. The role of the therapist according to Beck is to help the client reframe and then act based on more realistic and truthful cognitions, which then results in reduced symptoms or cravings. A variety of cognitive and behavioral strategies are utilized in CT. The CT approach should assist the client in monitoring negative, automatic thoughts, recognizing the connections between cognition, affect and behavior, and examining the evidence for and against negative, sometimes distorted automatic thoughts. The CBT model for substance abuse is collaborative, active, utilizes a Socratic method of questions, and is highly structured and focused. The principles of CBT for substance abuse seek to reduce the intensity and frequency of the urges by undermining the underlying belief system and teach the patient specific techniques for controlling or managing their urges. Simply put, the goal is to reduce the pressure and increase control. One of the advantages of using CBT with addictions is that CBT can also be used to treat coexisting psychiatric disorders, such as depression, anxiety, and anger issues which often accompanies substance abuse.
Once the faulty cognitions have been identified, the therapist may coach the client on implementing effective reframing techniques, which can assist the patient to substitute more reality, oriented interpretations for overly negative thoughts. The goal is to help the client learn to identify and alter dysfunctional beliefs which predispose him/her to distort life experiences. Cognitive Therapy, in contrast to psychoanalytic therapy, focuses on the here and now problems. However, childhood experiences may have relevance when used to clarify present observations. According to Beck, the general assumptions on which cognitive therapy is based, include the following:
- Perception and experiencing in general are active processes, which involve both inspective and introspective data
- The client’s cognitions represent a synthesis of internal and external stimuli
- How a person appraises a situation is generally evident within their cognitions (thoughts and visual images)
- These cognitions constitute the person’s “stream of consciousness” or phenomenal field, which reflects the person’s configuration of individual self, his work his past and future
- Alterations in the content of the person’s underlying cognitive structures affect his or her affective state and behavioral pattern
- Through psychological therapy a patient can become aware of their cognitive distortions
- Correction of these faulty dysfunctional constructs can lead to clinical improvement
Schemas
Beck refers to cognitive structures that organize and process incoming information as schemas. They represent thought patterns usually acquired early in an individual’s development. Relatively stable cognitive patterns form the basis for the regularity of interpretations of a particular set of situations. The term schema is used to designate these stable cognitive patterns. The schema is the basis from which the client or individual molds data into thoughts. Schema forms the basis for screening out, differentiating, filtering, and coding stimuli that confront the client. Individuals use schemas to categorize, organize, and evaluate their life experiences. According to Beck’s experience with substance abusers, schemas generally fall into two categories: (1) “I am unlovable” or (2) “I am helpless.” Offshoots of these two schema could be described as “I am trapped,” “I am inferior,” “I am ineffective,” “I am powerless,” “I am unwanted.” These types of schema are often associated with individuals suffering from substance abuse primarily because the individual believes the drug(s) will in some way provide solutions to their negative schema through faulty information processing.
Faulty Information Processing (Cognitive Errors)
Beck believes that individuals suffering from substance abuse make “systematic errors” in their cognitions, which actually serve to perpetuate negative ideas and thoughts regardless of the contradictory evidence available to the contrary. Beck has identified the following as common systematic errors:
- Arbitrary inference—basing a conclusion in the absence of evidence to support the conclusion or when the evidence actually contradicts the conclusion.
- Selective abstraction—focusing on a detail taken out of context, ignoring other important features of the situation.
- Overgeneralization—construction of a general rule on the basis of isolated incidents and then applying that rule across the board to related and unrelated situations.
- Magnification and minimization—placing an inordinate amount of significance to an event that is clearly distorted.
- Personalization—refers to the client’s proclivity to relate external events to himself when there is no basis for making such a connection.
- Absolutistic, dichotomous thinking—is the tendency to place all experiences in one of two opposite categories; for example, perfect or defective, clean or filthy, saint or sinner. Basically this is an either/or cognition.
Addictive beliefs include the following:
- I need the substance (drug) if I am to maintain my psychological and emotional balance
- When I use, I can function better in social settings as well as increase intellectual capacity
- I expect that when I use, I will derive pleasure and excitement from the drug that I cannot find anywhere else
- The drug will provide me with energy and increased power
- The drug will sooth and calm me down
- The drug will relieve my boredom, anxiety, tension, and depression
- Unless something is done to satisfy my craving, it will continue indefinitely and possibly get worse.
In addition to addictive beliefs, the user may also exhibit a variety of permission-giving-beliefs and entitlement thinking which minimizes risks in the patient’s mind. Examples of these beliefs include, “Since I’m feeling bad, it’s OK to use,” “I’ve been having a hard time so I deserve to use and get relief,” “The satisfaction I get is worth the risk of relapsing.”
Core addictive beliefs activate emotions that may eventually lead to the addictive behavior.
Core Beliefs
I am trapped / alone.
Addictive Behavior
Visits Crack House
CBT is aimed at modifying each of the categories of beliefs: anticipatory, permissive, as well as the underlying core beliefs that potentiate these drug related beliefs. When the addicted person’s core beliefs interact with life stressors, they produce anxiety, worry, dysphoria or anger. These stressful or stimulus situations activate drug related beliefs that lead to craving. Beck asserts that basic faulty, incorrect beliefs and automatic thoughts about drugs, their perceived benefits and uses, may account for increased substance abuse.
Case Formulation
It’s important to obtain a thorough case history which examines all relevant childhood information and family dynamics. The essential components of case conceptualization include relevant childhood data, current life problems, core beliefs or schemas, conditional assumptions, compensatory strategies (survival techniques), vulnerable situations, automatic thoughts and beliefs (specifically related to drug use), emotions, behaviors. This helps the therapist to conceptualize the basis for the client’s core belief system and assumptions. By understanding the client’s conditional assumptions and belief system, it helps the therapist to understand and identify the compensatory strategies the client may have developed as a result of childhood experiences. For example, if the father of the client was an alcoholic, verbally abusive and humiliated the client as a child, the client may have developed a core belief system that says, “I’m unloved, unwanted.” This leads to the conditional assumptions, beliefs and rules that say, “If I do everything perfectly, then people will like me and I’ll feel comfortable,” or if I show others how I really feel, they will abandon me.” The compensatory strategies or “survival personality” that flows out of this type of thinking could be “I’ll use drugs when I am uncomfortable because they will make the pain go away,” or engage in isolation and withdrawal or “Don’t do anything unless you are 100% sure you can succeed,” or “Don’t show others how you really feel.” Establishing a complete case formulation helps set direction for therapy sessions and provides the specifics necessary to develop meaningful assignments and goals for the client.
Homework
Homework or assignments for the client to complete outside of the therapy session is a valuable component of CBT for the substance abuser. As in all other applications of cognitive therapy, homework assignments allow the client to apply and practice the skills learned during sessions. Homework assignments can be useful to reinforce and embed the self-guided techniques of Socratic questioning, (e.g. “What evidence do I have for this thought or belief?”) within their everyday lives. The authors provide several examples of homework assignments that can assist the therapist and patient with recognizing faulty thoughts and how to substitute rational cognitions. The Advantages/Disadvantages Analysis Chart allows the client to document in a chart the advantages and disadvantages of using and abstaining. This can help the client identify, review, and recall in very specific terms what the pros and cons are of using or abstaining.
The Daily Thought Record (DTR) is an effective tool, which serves as a standardized form for listing and modifying maladaptive thoughts. In the case of cocaine addiction, it is useful for modifying addictive beliefs that lead to urges and craving. Specifically, the DTR has five columns labeled, situation, emotions, automatic thoughts, rational response and outcome. The patient is instructed to document their experiences of urge and craving using the chart. They are asked to describe their situation and the actual event leading to the unpleasant emotion or stream of thoughts. Based on the situation, they are then asked to record their automatic thoughts that preceded their emotions. They are asked to document their emotions such as hate, anger, rage, frustration, depression, or sadness. Recording rational responses reinforces positive reframing. Reframing is a salient goal of CBT because of the negative, often untrue and unrealistic cognitions that arise automatically.
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