Tag Archives: Cognitive Therapy

March 5, 2008 · 5:35 am

Integrative Psychotherapy VIII: Symptom reduction of anxiety


If you recall from prior chapters, McMinn and Campbell propose a 3 tiered model (IP) to address symptom, schema, and relationship issues. In chapter 7, they explore symptom focused interventions for anxiety (while not denying or addressing relational or schema matters of anxiety disorders). The authors provide a description of 5 types of anxiety problems (panic, phobias, OCD, PTSD, and GAD) and typical Cognitive Therapy interventions for each. For example, they describe panic as a “fear of fear” and explore interventions designed to interrupt the cycle of “internal physiological events” and “fearful appraisal of physiological sensations.” Such interventions include cognitive challenges or reframes, breathing and relaxation, and exposure (in vivo or imaginal) coupled with relaxation training. 

After providing this review of anxiety and common interventions, they move to a very brief discussion of fear from a spiritual perspective. The opposite of fear is love (not courage). They conclude that fear is, “a great spiritual problem” (p. 236). But, they quickly say, “we should not attribute anxiety problems to spiritual weakness.” They argue that doing that sets up an inappropriate simplistic model (you are anxious because you are immature) and ignores the complexities of fear. They fear it may also send the message that only people with anxiety cause their problems, when in fact we all live “outside of Eden.” So, our bodies, our communities, our wills are all tainted with sin. But, they say, “it is damaging and unrealistic to assume direct and immediate connections between a particular problem and spiritual maturity.” What should we do? “Our best response is to recognize our own brokenness so that we can, in humility, become people of compassion and understanding, willing to walk alongside others through the difficult passages of life.” (p. 236)

My thoughts? This is a classic CT review of anxiety. I’m not sure I saw much of their theological model of persons in this chapter. However, I have to remember this is a chapter designed only to address the symptom reduction aspects of therapy. The authors did not intend to look at relationships and schemas. In the real world, we can’t separate out schema and symptoms and deal with only one and not the other. I understand why they do highlight interventions in each domain in the book, but it comes at a cost (realism). I do wish they would have included a chapter on putting it all together by following a particular case. I also wish they would keep following anxiety problems through the other 2 domains of the model, but they didn’t.

My bigger concern is the thin discussion on spiritual aspects of fear symptoms. Now, maybe they will pick up more when we get to schemas since schemas look at worldview and beliefs. But, while I agree completely with the last quote above, I think they make an all-or-nothing proposal. They are right that judgmentalism and simplistic understandings of fear are inappropriate. However, avoidance tactics found with panic symptoms do reveal implicit demands for control beyond what God intends. Symptoms both happen and are chosen. These demands that we make may be unconscious and may be completely understandable. And yet, I believe we can explore symptom maintenance and reduction AND talk about spiritual matters without equating spiritual maturity with the elimination of all problems.   For example, OCD symptoms such as worry that one has caused harm to another (e.g., hit someone while driving to work) can be best treated by cognitive challenges, imaginal exposure and response prevention. But as one attempts these interventions it is likely that conversations arise about the desire to avoid causing anyone harm. Now that is a deeply spiritual conversation–and I suspect the authors agree. Hopefully we’ll see some discussion of this in the next two chapters as they look at schema issues.  

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February 28, 2008 · 5:23 am

Integrative Psychotherapy VII: Functional Domain Interventions


McMinn and Campbell start out chapter six (a deeper review of the 1st domain of interventions, that of addressing symptoms) with this helpful insight: “Many of our graduate students select psychology as a profession after deciding against one of two alternative career paths.” Some are tempted to pastoral ministry and so see psychology as a way to care for human souls. Others are tempted to medical practice and so see psychology as a way to, “help people find relief from their troubles” (p. 177). This distinction is helpful in explaining why some of us hang out in one type of intervention over another.

But whatever one’s interests, everyone must address presenting problems and not bypass symptoms as these are what bring people in to therapy in the first place. So, the authors use this chapter to outline, in general, symptom-focused interventions, The next chapter will apply these interventions specifically to anxiety.

Right off the bat, the authors bring up emotions. They want to dispel the myth that cognitive therapist care little for feelings. They want to define negative emotions as either a sign of cognitive distortions and/or a warning sign that something is off in one’s life. [Hopefully, they do not fully believe that negative emotions means that something is wrong in one’s life. It may be something is wrong in the world…]. To achieve successful interventions in this domain, one must have good relational skills to listen well to both explicit and implicit feelings.

It comes as no surprise that domain 1 interventions include behavioral skills. The authors summarize classical and operant conditioning in a few short paragraphs and suggest that these techniques may help clients have dominion (through reinforcement strategies?) over their own behaviors and responses to life. Their lack of attention to behavioral mod. sends a message.

The bulk of the chapter then focuses on the basic of cognitive restructuring. They divide this task into two parts: sorting an experience into its component parts AND challenging distorted thinking. The authors describe the technique of the thought record and walk through several vignettes to show how it might be used. The record separates situations, thoughts, and feelings (and rates intensity of feelings/experiences on 1 to 10 scale). As the client gains insight, then the work is to counter the automatic thoughts with a rational response. The authors want to remind the counselor to avoid a disputing mindset when countering a client’s distorted thought patterns. Instead, they suggest a more collaborative approach or “Socratic method” using questions and reflections to lead the client to insight rather than drag them to it. 

Beyond the thought record, they describe other methods of changing one’s thinking: scaling (moving away from all/nothing thinking to put stressors in proper perspective), probability estimates (used when someone is worried about an unlikely event), decatastrophizing (helping to move away from “extremist thinking”), humorous counters (identifying silly thinking without making fun of), role-playing (reversing roles and having the client become the counselor), paradox (overstating the client’s fears to see the logical outcome), and cognitive rehearsal (repeated challenge to automatic thoughts).

Finally, they attempt to provide a Christian appraisal of these interventions. First, they tackle the problem of relativism that may underly CT by the biblical concept of testing and trying every “truth.” Instead of rejecting all client automatic thoughts by some sort of Stuart Smalley self-talk mantra, test their thoughts with Scripture, tradition, experience, and reason—aka Wesleyan quadrilateral. Then they give some examples of how a Christian collaborative response to a client with a difficult marriage might look different from a relativistic (be happy) response. The client and the counselor work together to explore what Scripture, tradition, experience and reason might bring to the table (these are not considered equally weighted of course) in discerning the truth about our selves and our thoughts about ourselves.

My thoughts? This chapter is solidly within the CT frame with the recognition that truth has a capital T. Our job as counselors isn’t to tell the clients the truth but to walk with them in a collaborative manner. It is good to see lots of humility in the chapter. We can abuse Scripture, overplay tradition or reason, become disputational, etc. What is missing from this chapter (maybe in comes later) is that while it is helpful to recognize logical errors, it is also true that logic does not always (often?) lead to better thinking. We have some pretty embedded views of ourselves that continue even in the face of our logic. How will they deal with this issue?

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February 6, 2008 · 1:15 pm

Integrative Psychotherapy IV


In chapter 3 of Integrative Psychotherapy, McMinn and Campbell provide a nice overview of a significant portion of their theoretical foundation–Cognitive therapy. They begin by discussing the so-called cognitive revolution in the 1960s (over against mechanistic behaviorism and the prior king, psychoanalysis). They remind us how this revolution continues to shape the landscape of mental health (empirically-validated treatments, short-term therapy, self-help books, etc.).

Going into more detail, McMinn and Campbell divide Cognitive therapies into 2 broad categories: Semantic Cognitive Therapy (SCT) and Constructivist Cognitive Therapy (CCT). What is the main difference between the two? SCT’s premise is that people attribute feelings to the events/circumstances in their life, but only simplistically–overlooking their interpretive thoughts about the situation. The authors provide this common diagram: Events -> Thoughts -> Feelings. SCT is designed to help folks critique their thought patterns and evaluate their rationality. Once this happens, it is supposed that individuals will then have more control over their feelings. They mention Albert Ellis’ REBT model: Activiating event -> Belief -> Consequential emotion. This leads to his treatment: Disputing irrational beliefs -> revised cognitive Effect. They also mention Aaron Beck’s additions to SCT in his description of Core Beliefs that color one’s view of the world and self and are highly resistant to change. While there are some benefits to SCT (revealing our tendencies to assume the worst, making mountains out of molehills) McMinn and Campbell find this model to oversimplify “the complexities of human change.” (p. 85).

CCT began to develop in the later 80s and 90s, per the authors, to address the problem of linearity in SCT. Instead of merely assuming that we react to events, CCT recognizes that how we shape events and feelings can also shape interpretations. “Our beliefs do not simply reflect a passive understanding or misunderstanding of reality; they actually change reality…” (p. 86). From this point, the authors go into a sidebar apology on constructivist philosophy, but not radical constructionism. “One can still believe in external authority and truth while acknowledging that human processes influence the actual events of everyday life.” Also, “Christians can and should accept the premise that personal values and perceptions of reality end up changing reality itself.” (p. 87) Unfortunately, CCT sputters and fades because of a new focus on Empirically Validated Therapies which are based on SCT models.

The remaining 20 pages of the chapter provide the authors’ critique of the the CT foundations and model. On the plus side, they see how CT has a lot of commonsense to it, has clear goals/objectives in focus, is time-limited, and supported by scientific research. As a model it does not have a deterministic mindset. Rather, CT believes in at least partial human agency–you can change how you think, see, feel, etc. You are not merely robotically determined by your past. On the negative side, they acknowledge that CT is rather disconnected from well thought out foundations. They call it a practical response to the frustration of analytic models. CT is, in their words, free-floating interventions without the foundation of a good theory. Further, they point out several false premises within CT and support with examples to the contrary: healthy people think rationally, cognitive errors are usually negative, healthy, rational people eliminate negative emotion, thoughts come before feelings, and we are motivated to be more rational. Finally, they charge CT with being “pragmatic rationalism” (I’d call it pragmatic modernistic rationalism) and point out the problem that it doesn’t deal well (at least as originally designed) with the importance of feelings, relationships, culture, fallen human condition, values, etc. in the process of change. They also point out that some of the Christian versions of CT fall into some of these false premises as well. “The Christian narrative is not primarily about correcting sloppy or ineffectual thinking. We are not taught in Scripture that the path to wholeness is found in better thinking. The bible is a narrative about humans being created for relationship with God and one another, struggling because those relationships are now tainted by the devastating effects of sin, and living with the hope of creation restored.” (p. 109).

My thoughts: I’m glad to see they critiqued the problems in CT. In fact, they did it so well, I’m surprised they didn’t do much more to defend why they keep it rather than looking for an entirely new model. Maybe that will get explained in the next chapters. They avoid the simplistic view that CT is similar to the put off/put on message of the bible. I’m glad they presented the material in the SCT vs. CCT description. I did wonder why CCT didn’t take off given its affinity with postmodern philosophies of science. I would quibble with their bible passages used to defend a chastened constructivism. I have no problems defending a form of social constructionism. But, the passages picked from 1 Peter have more to do about the fact that we influence others than about whether our assumptions about the world construct a portion of reality. I would have liked to see them build a more christian or theological model for CCT and relating it to emotions and narratival therapies. I understand the chapter was already getting long but I would have also like to see them connect the dots in other therapies that have cognitive features (e.g., emotion-focused therapy, Mindfulness, etc.).  

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