I keep trying to capture the essence of cognitive behavior management changework in its most simple and essential form. It seems to me that the constructs are simple, but that the field keeps trying to expand exponentially the language used to define it. As an example, I have now used the term cognitive behavior management to cover the range of activities from cognitive therapy [which generally is defined as correcting cognitive errors], cognitive reconstruction [which is generally defined as dealing with core beliefs] rational emotive therapy [which is generally defined as challenging irrational thoughts with rational logic], Psychosocial Rehabilitation [which is an actity oriented cognitive behavioral program]; NeuroLinguistic Programming [which defies definition]; occassionally psychoeducational [which includes social skill building]; cognitive behavior therapies [which seek to alter the way client construe themselves and their experiences; behavior therapy [which employs a wide range of methods nearly all of which overlaps other mentioned processes], under a single rubric.
All of these interventions use the same set of techniques and procedures and there is little use of defining them through different terminology except for the glorification of their creators and practioneers. We have in the past used the term cognitive rehabilitation, but increasining we found that people considered that different from all of the other terms. We selected rehabiltiation since it means to re-qualify. Thus, requalification of our thoughts seems to have some merit as our generalizaed term.
In attempting to organize the factors of this aspect cognitive behavior management , we have already identified in other writings, the components of Awareness, Attendance, Analysis, Alternatives and Adaption for correcting cogntive errors. To improve this outline, we need to be more specific about what we are being aware of, attending to, analyzing, finding alternatives for and adapting. This material is generated as an attempt to develop these responses in a manner which is generic to all helping situations.
At least two factors need to be articulated as background before we continue. The first is that in broad strokes, we consider three primary emotional contexts. These consist of fear, attraction, and anger. While there are many, many shades of variation and combination, these seem to us to be the primary emotional contexts. We can think of the three primary colors and how they are shaded into other colors as our analogy. To this configuration, we suggest that the major problems in living are easily placed within the confines of this primary triad: angry antisocial conduct, depression or anxiety, which fit neatly into these emotional contexts. The blurring of contexts into new colors can be seen in such problems as post traumatic stress, which embodies traumatic loss with fear of recurrence.
The primary triad context also helps us with a framework for evaluation as attraction has the continuum of loss to gain of a beloved object or experience. We either have lost, think we will lose, suspect we have lost or gained. Anger or its absence, on the other hand creates a direct interpersonal continum from hostile or amiable relations with others. Fear, of course separates into a continuum of threat to comfort. In this simplistic fashion, it seems that we can consider the details of each of the problems in living in similar categories.
The second factor is one best articulated by Eric Klinger [1993]. He suggest an “extensive linkage between emotion and cognition at both the molar level, on which moods and cognition influence each other, and at a much more molecular level on which emotional and cognitive processes are intertwined in the production of individual emotional reactions and cognitive events. Both emotion and cognition are in turn determined by motivational state [emphasis added] – by the goals to which people have committed and the incentives available to them.”
The significance of goals is, in my opinion, the most undervalued construct in all of psychology. Klinger goes on to state that it appears that “mood and cognition affect each other bidirectionally.” “What people attend to, recall, and think about is determined to a substantial extent by their current concerns, meaning the nonconscious internal states that correspond to pursuing particular goals. When we encounter cues associated with our goal pursuits, these cues tend to elicit cognitive processing. If our concerns are predominantly about avoiding threats, as in anxiety states, we keep noticing and thinking about cues of threat; if we are depressed while disengaging from a loss, we keep noticing and thinking about cues of loss and helplessness.”
Thus we must combine the concern [motivation] as linking directly to cognition which is interactive with emotions, which can be clarified by the following figure
emotion cognition
Motivation, the ability to develop a purpose or meaning for life, may be the single, most influential factor to quality living. We will not reiterate here the seminal work of Viktor Frankl in developing a meaning for life, a telos [for the sake of which] a life is lived. Without a clarity of meaning, purpose , and goals – the ability to decide what is valued or not valued becomes very difficult, if not impossible. Klinger articulates what we have stated elsewhere that emotions are an evaluative and valuing process. “…emotions assign values to the events that elicit them, or they reflect or even constitute those values. Unlike cognitions, emotional responses incorporate a valence and a mobilizing mechanism, an innately specified linkage of specific stimuli with arousal and action tendencies. Thus emotion transforms information into behaviorally meaningful evaluation.”
Cognition, on the other hand can be viewed as analyzing ambiguous data when the person does not know what value to assign. Therefore, cognition mediates emotion, which mediates behavior or action.
From a clinical perspective, then we have an opportunity to set the stage for what values are to be assigned to various cues, what cues will be attended to, and what memories will be recalled, by focusing the individual on their own intentions. It is with this in mind, we start the cognitive outline.
Awareness
While traditionally the focus is on awareness of present or current traits of thoughts and feelings; or states of beliefs and moods, we suggest that one might consider starting at the core of the problem – the mental state of intentionality. Without a defining summum bonum [life’s greatest good], there is not ability to measure right action and without right action, there is no coherence. As we have stated elsewhere goals are hierarchal in nature with the superordinate goal at the top, and a host of sub- and sub-sub goals below. The goals tend to be coherent, so that the events today are valued and the automatic thoughts are in accord with the superordinate frame of reference. We don’t normally think of this as a goal structure, since it is nonconscious. But if we believe certain things about ourselves and other, we respond to those things in ways that are coherent with us [our beliefs, attitudes, thoughts, etc which comprise our individual personality]. It cannot be any other way. We are the sum total of our thoughts.
It is not a trivial understanding that people with the most severe and persistent problems in living have the least well formed superordinate goals. In fact, merely raising the question of goals might trigger for the first time a conscious awareness of the lack. Certainly the angry and depressed will tend to indicate that they have no goals and they don’t expect to be around very long. This is the fringe of homicidal and suicidal thinking from which there is no continued life. The severely anxious may have the same expectation of the end, but it is out of their control. The request to focus on the future, on the purpose, on the goals and intentions; the awareness of themselves in the cosmos is a movement away from the pathos of their lives.
This redirection also is an attempt to frame the components of awareness: perceptions in the forms of cues and recall; automatic and core thoughts; the sensations of the body; and the specific intentions to be applied.
Attendance
Since 95% of what occurs is nonconscious, attendance indicates what we voluntary bring into consciousness. Clinicians have many methods of ensuring attendance by clients such as journals, counting, mantras, etc. What is used to ensure attendance is not as important as to what is attended to. As we have indicated we need to have clients attend to:
Cues and recall: what is it that the person perceives in the inner or outer world? If s/he is always seeing threats, it is important to quantify the number and qualify the intensity of these threats. This is so that s/he will have material observations to analyze.
Body sensations: what are the physical feelings that occur when an event is experienced? Does the hair stand up on end? Is there a feeling in the pit of the stomach? Do the palms sweat? When does this happen? How often does it happen? What is the frequency and intensity? Do we have appropriate language and concepts to identify it?
Automatic thoughts: when cues or memories are being consciously attended to: what thoughts do they engender? What emotional labels are used: rage, displeasure, bitterness? What are the attributions made about cause and effect? What judgments are made about self and/or others?
Intentionality: what were you intending to accomplish? Was the experience a barrier or support?
Analysis
Analysis occurs pragmatically. Is the element helpful or harmful to the individual and his/her goals? Are they rewarded or punished by the element being analyzed? Is the cue, thought or sensation a threat or comfort; loss or gain; or indicative of a hostile or amiable relation? One may also examine whether the judgement or valuation is true, in the sense of examining the context of the element and the frame of reference.
Cues and recall: What other cues or memories exist in the inner or outer environment that may support or deny the perception made? Through metaperception, the person can be asked to relive the situation from associated or dissociated positions to see if any other observations can be made. They can be asked to review their journals to see if other aspects exist which were overlooked.
Body sensations: are the sensations pleasant or unpleasant? Are the sensations connected to specific types of events? When pleasant sensations occur, what is happening. What labels are used to define the sensations? How frequently do they occur and in what intensity? Is there anything that reduces the intensity of unpleasant feelings? Is there any way to avoid events and experiences which cause unpleasant feelings? Is such avoidance helpful? Is there any way to increase the occurrence of pleasant feelings?
Automatic thoughts: Do these thoughts fall into the ‘cognitive error’ list? What kinds of cognitive errors occur? Are there one or two consistent errors? Are the thoughts correct/true? Are they helpful?
Intentionality: Does the concern ideation and subsequent thoughts and feelings interfere with the intentions/goals/summum bonum? Do you have a clear goal implementation plan?
Alternatives:
If the analysis demonstrates that the concern ideation and subsequent thought and feeling are interfering with the intentions; the client clearly needs to seek alternatives or suffer the continuation of the problem. If hostile attribution continues to create difficult interpersonal relations – it must either be changed or there will continue to be such interpersonal problems which are barriers to the client reaching his/her goals.
Cues and recall: it is difficult to change perceptions until one changes the concern ideation. In order to do this, several prostheses might be used:
- clients might develop mantras which self instruct to look for other cues or to avoid accepting the present cue structure.
- clients might keep journals in which they record the cue and an alternative cue.
- clients might metapercieve common events in which problem cues occur and perceive them with other more positive cues occurring
Body sensations:
- clients might reconsider the label that they have applied to the sensations generated: changing the intensity of the feeling.
- clients might metapercieve the experience and examine the sub-modalities of the body sensations and change them.
- clients can practice and use relaxation techniques to change the intensity of the sensations.
Automatic thoughts:
- clients can create alternative thoughts which are made into a mantra to be repeated consistently [reframing].
- clients can use journals to slow down the thoughts so that they can be reconsidered.
Intentionality: clients can revise their goal implementation plans to incorporate the alternative strategies. Clients can develop self reward statements for all achievements of implementation steps.
Adaption
Clients will implement their goal implementation plans using all of the alternative measures in their arsenal. This process is formatted as a self management strategy in which the person self instructs, self evaluates and self rewards. When difficulties arise, clients can ‘future pace’ to develop anticipatory strategies for events and experiences which are difficult and to inoculate themselves against relapse.
Closure
The client must ultimately choose to resolve his/her problems in living. There are many reasons why change may not be perceived as beneficial. Hopefully the clinical practitioner has been able to identify these and resolve them However, it always boils down to client choice. They can choose to be crazy.