COGNITIVE BEHAVIOR MANAGEMENT
Behavior
Stimulus ———————————————–→ Response
Elements:
Modeling
Behavior rehearsal
Feedback
Reinforcement
Cognition
Stimulus ——→ (covert behavior) ——-→ Response (overt Behavior)
Definitions:
Covert behavior: cognition – mental processing (thinking) of mental representations that include:
- Concepts: generalization or abstractions of associations of things – thoughts
- Intuitions: hunches, instincts. Visceral or ‘gut feelings’ – quirks
- Values: based on the utilitarian construct of pleasure/pain a value label is applied to important concepts or intuitions – emotions
- Qualia: sometimes called submodalities – the elements of out senses – e.g., vision = color, movement, brightness, etc. = the raw material of perception – sensations.
Elements
Metacognition – thinking about thinking. A process of being mindful – as a meditator might focus attention on what is going on in his or her mind. It is estimated that 95% of what we do is nonconscious. When one begins to think about thinking they are making their thoughts conscious. Consciousness or voluntary attendance makes it possible to ‘debug’ faulty thinking.
Metaperception – perceiving from different frames of reference – e.g., seeing oneself interacting with another person as though on a movie screen. Once can also imagine oneself viewing oneself sitting in a movie theater watching oneself on the screen. When in the scene as the actor – this is called the first position. Imagining oneself in the theater watching the movie of the scene is the second position. When sitting in the balcony watching yourself watching yourself on the screen is the third position. How many positions are possible has not been determined. Often called visualization, it is more appropriately termed imagery since all of the senses are involved. Each position moves you further from association and therefore emotional involvement. Dissociation allows one to relive the experience at different levels. Once can also use other dimensions of change such as location or time. You can go into the past or the future in your imagination and to a tropical island or Iceland.
DISCUSSION
Through a process of being mindful of one’s cognitions [meaning all covert behavior] e.g., making one’s thoughts conscious [voluntary attention], one can ‘debug’ or change the thoughts that are distressful. This is a five-step process starting with awareness. The thoughts that are most often reviewed are ‘automatic thoughts’ which like other automatic or reflexive behaviors [e.g., blinking, breathing], occur without consciousness. Automatic thought are connected to the belief system or theory of meaning that a person has about both conventional [restaurants] and personal [self & others] schemata [an organizing system that covers all cognitions about the subject]. Three levels of cognition can be identified:
- core beliefs: the basic beliefs of the individual which create his or her reality and ‘inner logic’.
- organizing beliefs: the system of bringing together the beliefs that matter to address the domain of interest [schema – schemata]
- processing beliefs: the beliefs that are used in the human thought steam to assess a situation, attribute cause, make judgements and determine disposition that is always going on in an automatic or reflexive way
This separation is my own and does not appear in the literature, but provides a helpful way to understand the usage. The term belief does eliminate conventional thinking and refers to thoughts that have important valuation or emotional attachment. Whether you love it or hate it; it has important meaning to you. You may know the square root of twelve, but not be overly upset if someone comes along and says that your answer is wrong. The value is an added personal meaning – if you are a mathematician, you might be vehemently angry about a new theory of square roots. That is because you believe the present system to be right – thought plus emotion = belief.
While we are concerned about all three levels of beliefs, the first attention is to the processing beliefs or automatic thought. These ‘leak’ through self-talk – in other words, we say thing to ourselves that reflect our core beliefs and schema and at times of performance stress we sometimes say these things out loud. Automatic thoughts have certain characteristics. They:
- often appear in shorthand, composed of just a few essential words phrased in telegraphic style: “lonely . . . getting sick . . . can’t stand it . . . cancer . . . no good.” One word or a short phrase functions as a label for a group of painful memories, fears, or self-reproaches.
- are almost always believed, no matter how illogical they appear upon subsequent analysis.
- are experienced as spontaneous. You believe automatic thoughts because they are automatic. They seem to arise spontaneously out of ongoing events. They just pop into your mind and you hardly notice them, let alone subject them to logical analysis.
- are often couched in terms of rules: should, ought, or must. People torture themselves with “shoulds” such as “I should be happy. I should be more energetic, creative, responsible, loving, generous….” Each ironclad “should” precipitates a sense of guilt or a loss of self-esteem.
- when negative they tend to “awfulize.” These thoughts predict catastrophe, see danger in everything, and always expect the worst. A stomachache is a symptom of cancer, the look of distraction in a lover’s face is the first sign of withdrawal. “Awfulizers” are the major source of anxiety.
- are relatively idiosyncratic. In a crowded theater a woman suddenly stood up, slapped the face of the man next to her, and hurried up the aisle and out the exit. Each witness to this event reacted in a different way.
- are persistent and self-perpetuating. They are hard to turn off or change because they are reflexive and plausible. They weave unnoticed through the fabric of your internal dialogue and seem to come and go with a will of their own. One automatic thought tends to act as a cue for another and another and another. You may have experienced this chaining effect as one depressing thought triggers a long chain of associated depressing thoughts.
- often differ from your public statements. Most people talk to others very differently from the way they talk to themselves. To others they usually describe events in their lives as logical sequences of cause and effect. But to themselves they may describe the same events with self-deprecating venom or dire predictions.
- repeat habitual themes. Chronic anger, anxiety, or depression results from a focus on one particular group of automatic thoughts to the exclusion of all contrary thoughts. The theme of anxious people is danger. They are preoccupied with the anticipation of dangerous situations, forever scanning the horizon for future pain. Depressed individuals often focus on the past and obsess about the theme of loss. They also focus on their own failings and flaws. Chronically angry people repeat automatic thoughts about the hurtful and deliberate behavior of others.
Preoccupation with these habitual themes creates a kind of tunnel vision in which you think only one kind of thought and notice only one aspect of your environment.
- are learned. Since childhood people have been telling you what to think. You have been conditioned by family, friends, and the media to interpret events a certain way. Over the years you have learned and practiced habitual patterns of automatic thoughts that are difficult to detect, let alone change. That’s the bad news. The good news is that what has been learned can be unlearned and changed.
The second step is to attend to the thoughts. To be mindful over time is difficult, we can only hold things in consciousness for short periods of time. By using recording techniques [journals] a person is able to attend to their thoughts over time and compare actual thinking from different points rather than rely on memory.
Part of the attention is used to analyze the thoughts. Because we have a confirmation bias or a bias towards believing what we think, we need to do this analysis in a formal manner – using a scientific method – and to do it in public – before someone else. The counselor’s role then becomes one of acting as a mirror – reflecting back to the client what s/he is doing, pointing out errors and perhaps disputing meaning.
Meaning is a very important aspect of cognitive change for there is no meaning until a sentient being gives it meaning. A person killing someone else is murder, self-defense or a combat soldier’s duty depending on the frame of reference of the person determining the meaning. The meaning is determined through a process of reviewing all other prior circumstances and determining what this means to you. Offering a steak dinner to your guest is a sign of caring or a mean spiritedness depending on your guest’s perspective on red meat, animal rights and all other concepts and intuitions that they have acquired. If they were traumatized in a slaughter-house in their childhood they may actually show disgust and threaten attack. What we are talking about here is an ‘inner logic’ that each person has based on their own experiences, and more importantly, their interpretation of those experiences.
The ‘inner logic’ or Theory of Meaning becomes the reality of the world. If I believe that all people are nasty and evil, I might have constant automatic thoughts about people trying to hurt me. I might also decide to hurt them before they can hurt me. People with problems in living usually have an idiosyncratic inner meaning that differs from that of most of the people they relate to. When this happens, analysis of their cognitions in a formal and public manner can help to identify distressing meanings and outcomes.
Once a distressing thought is identified, the next step is to find a way to change it. One part of this is to identify alternative thoughts or meaning which are less distressing or lead to less distressing outcomes. This is to some extent a creative process to seek balanced and rational thoughts. The more replacement thoughts you can come up with, the easier this process will be. The counselor may model different thoughts although it is considered generally more helpful for the client to generate the balanced and rational thoughts themselves. They may use other models in this process, thinking about someone who they believe handles the circumstances well and considering what they might be thinking. The counselor may ask the client to rehearse the problem situation using the replacement thought as a means of seeing how it fits. The counselor gives feedback regarding the balance and appropriateness of the replacement thoughts. The counselor reinforces appropriate balanced and rational thoughts that the client has determined fit his or her situation.
It is one thing to have a new thought it is another to adapt to that thought. Adaptation to new thoughts can happen instantaneously if they fit so well within the client’s inner logic that they can simply be assimilated or accommodated. We change our thoughts often through these processes – otherwise we would never mature. However, if the distressing thought is well embedded in the nonconscious functioning it may take a while to adapt to a new thought. A process called habituation is how we learn.
Remember learning to ride a bicycle? You thought you would never learn to balance. Since balance is easier with more speed, but going faster is scarier – it was a struggle. But at some point you overcame your fear and moved fast enough to balance. At some point later you simply got on the bike and rode. You did not think about balance and speed – you simply did it. In fact, sometimes if you begin to think about it – this can cause problems. Lets discuss walking, which is another learned behavior. You walk all the time without a thought about balance. Yet if I lay a four by four on the floor and ask you to walk on it, you will suddenly have balance consciousness. You become aware of the need to balance and you attend to your balance. If you did this every day, you would learn to walk on the four by four without thinking. This is habituation. Just learning a new thought does not mean it will become automatic. However, given two thoughts, the brain will tend to use the one that is most comforting. Since the one you are replacing was distressing, this new balanced and rational thought should be more comforting. There is actually a process of wiring and rewiring the brain that takes place, so that ultimately the alternative thought becomes automatic and the resultant meaning and emotion change followed by different behavior.
This is all too easy, of course. For people with serious and persistent problems in living the distressing thoughts may be quirks. Remember that quirks are intuitions, hunches, visceral or ‘gut’ feelings. These cognitions are ineffable – you cannot say very much about them. How do you make a balanced and rational replacement for something you cannot even consciously comprehend? This indeed is a more rigorous process. Usually the person can articulate the emotional value of the quirk – “I’m worthless” – and do so through their self-talk [leakage from the inner logic]. But when asked why they believe that they are likely to be only able to answer in a metaphor – “I feel so dirty!” or with more outcome explanations – “no one likes me.”.
Two methodologies are often used to help get to the core beliefs. The first is the unanswerable question. This can be asked in many ways, but for example, the counselor might ask: “if this were true, what would it mean to you?” Whatever the answer, the same question is asked again until finally the person has no more answers. In a similar vein, the client can be asked to ask a part of him/herself, questions that are unanswerable. An example might be – “I want to quit smoking, but I can’t”. That implies that a part of you wants to quit smoking and a part of you doesn’t. Have the part that wants to quit smoking ask specific questions that can be answered yes or no as to why the part wants to smoke. Usually, what happens is the person will get sensations that they will then interpret as answers. Is one part really talking to another? Well, I don’t know that we can answer that without a whole philosophical discussion about self, but we can know that whatever the outcome of that discussion, the response is from the individual. The answers will meet the client’s needs because subconsciously they fit the inner logic.
Solutions focuses brief counseling has an unanswerable ‘magic’ Miracle Question that has to be asked in the following way:
“I’d like to ask you a strange question… Suppose…that you go home tonight…and go to bed…and fall asleep as usual…and while you are sleeping, a miracle happens…and the miracle is that the problems that brought you in here are gone…and you don’t know because you are sleeping… What will you notice different tomorrow…that will tell you that there has been a miracle?”
Follow up questions serve the purpose of getting a description in specific, small, positive and interactive terms. But you get the point – this is an imaginary question that has no answer. The way the client answers the question includes the solutions to the problems that are acceptable to him or her.
Another metaprocess is that of imagery. If a person has a quirk, it probably formed in childhood before language was the predominant method of thinking. By having the person imagine experiences in childhood of their own choosing and reliving that experience from the present day perspective, you are often able to change the meaning of the experience. In a reparenting strategy the younger client of the past can be comforted by the older client of the present and the experience becomes different.
Finally, there is a method of changing the qualia or submodalities that are stored in memory. The memory of an event is coded in a way that includes the emotional quality. Thus, when you think about an event that happened at an earlier time you will bring forth the emotional characteristics of that event. Fear, anger or elation may return. How are these emotional values coded in memory? It seems they are coded as qualia – joyful memories are brighter, more colorful, closer, etc., while traumatic memories are distant, darker, etc. If the person can imagine the moment as dark and sinister and then change the qualia to bright and colorful, the emotional value and meaning changes. It must be indicated that these results for changing the qualia are anecdotal and not empirically validated. Partially, this is because of the refusal of the traditionalist to entertain the intervention as valid.
LETS COMPARE
Cognitive interventions are behavioral. They use modeling [imagining a potential future situation and the appropriate way to handle that situations], covert behavioral rehearsal [imagining the situation, process and outcome], feedback [discussing what worked and did not work], and reinforcement [self-reinforcement and social reinforcement support the counselor reinforcement].
As a result, they are of an entirely different order than psychodynamic and biomedical approaches. It is inappropriate to group these three orders together under the guise ‘psychotherapy’.
Cognitive behavior management deals with behavior, overt and covert, and places the client in a position of choosing to perform differently based on the reinforcement [whether internal or external]. The change agent is the client and the problems dealt with are real world problems.
Psychodynamic approaches are presumably based on drives that are in conflict and it is the working out of these conflicts that matters. These are abstractions and not real world problems. Further, psychodynamic counseling is an expert model in which the counselor is the agent of change and makes all of the decisions since the individual person is incapable of making the right decisions. CBM is an enabler model.
Biomedical approaches are based on the assumption of pathology [genes, germs or chemistry] and no amount of counseling is going to help the client change his/her behaviors because s/he has no capacity to change. Therefore, it is up to the doctor [another expert model] to control the behaviors through medication or incarceration. Any counseling that occurs is to help the client live with these facts.
These are three specific levels of abstraction and are not compatible. Psychodynamic and biomedical approaches are combined only because psychodynamic counseling has no effective benefit. The medication is then added to make the process of change effective, if not beneficial. It is not beneficial since it only meets the dead man test. First attributed to Ogden Lindsley, the dead man test is a means of determining if outcome objectives are properly specified. That is, if a dead man could fulfill the criteria, that objective is inadequate. Thus any focus upon reduction or elimination of excess behavior would meet the test of the dead man test, since a dead man does nothing, but would be unacceptable helping.
Cognitive behavior management approaches cannot be additive to biomedical because the concern is about covert behavior and to give the message that you are not responsible for your behavior is diametrically opposed to the construct – you are the sum total of your thoughts. CBM is not compatible with psychodynamic counseling because it does not support the notion that ‘drives’ control your thought or your behavior. The cognitive theory would posit that your thoughts control your ‘drives’ – at least within the range of reasonableness. Your hunger may drive you to steal food, but your thought that you may starve to death and that to avoid such an outcome it is worthwhile breaking the law is the reason for the behavior. You can, and some people do, choose to starve to death.
To include CBM with the other two approaches is to suggest that good chess players would make good football players because they are good at games. The absurdity of the difference of order therefore raises the question – why is it done? There seem to be several reasons. The first, and most important is that both psychodynamic and biomedical approaches are absolute failures. Psychodynamic approaches have no redeeming value except perhaps the relationship between the counselor and the client. A trust relationship with anyone is beneficial. Biomedical approaches are far, far worse and do not even have the benefit of relationship – the imperious nature and arrogance of psychiatrists are legendary. Further, the cure is toxic and works in the same manner as chemotherapy does – it breaks down cells. For chemotherapy that includes good cells as well as bad cells. But the cells we are talking about here are neurons – specialized cells of the brain. Not only that, but the toxic effects are directed at every cell of the brain, not some set of cells that have been identified as malignant. Thus the biomedical approaches not only destroy the persons will to be responsible for their own behavior, but the capacity as well. And the message they send to individuals and society is: if something is bothering you – take drugs! A nasty message indeed, and one that has led to a drug epidemic in the country.
CBM is a horse of a different color. It sends good messages and allows for personal responsibility and freedom. It supports the strength of the client and teaches skills so that the client can take control of his or her own life. Don’t call it psychotherapy!