Cognitive Therapies

The Galovski et al. (2015) paper discusses Cognitive Processing Therapy (CPT) as it works to treat PTSD in a manualized way. It also addresses special considerations. I really liked Molly's case example, for I feel like it exemplified how CPT would look and provided common cognitive distortions someone may have that on the surface appear rational, but are not in line with reality. This example also helped me understand the authors' comment of not getting caught up in all of the client's cognitions, for it is only the ones that are relevant to the trauma that should be targeted in CPT. Because personalities are so varied and therapy sessions often involve other life content, I think adherence to the disorder, criteria, and maintaining factors is especially important in cognitive therapies. Toward the end of the article, the authors discussed how modifications in the treatment should be avoided unless a patient's symptoms preclude comprehension, safety, or engagement. However, PTSD as a diagnosis appears to have some symptom components (avoidance) that vary cross-culturally as well as depending on the type of trauma, it feels like adaptation may be necessary. Additionally, criteria 2 (negative appraisal) seems like it would be very culturally dependent on an event. Therefore, it feels like some of the steps, worksheets, and weeks in CPT should be modified based on how much the client is struggling with those symptoms, and how culturally important other symptoms are. I also notice how CPT does not seem to acknowledge some of the external circumstances such as mass trauma, when someone has to return back to the place where the trauma may occur again, and interpersonal factors. 

The Gallagher & Resick (2012) article discusses mechanisms of change in CPT and in PE for PTSD. Specifically, it focused on the specific mechanisms of exposure and hope. Both CPT and PE are effective treatments for PTSD, but CPT focuses more on the cognitive elements, and PE focuses more on exposure and habituation. As talked about last class, it seems that PE used to focus more on this idea of habituation in comparison to inhibitory learning. I wonder if this study was redone to look at inhibitory learning, what the results would be. Overall, I liked the idea of this study, but since it was done with a previously collected dataset, they could not establish temporal precedence, had high dropout rates, and were unable to look at SUDS in the CPT group. Therefore, it felt like not the most robust comparison test of mechanisms. Additionally, I believe that problems such as treatment dropout are much more important to study compared to mechanisms, for I would rather have 80 participants fully partake in a therapy with 70% effectiveness than 50 participants partake in a therapy with 90% effectiveness. Although that is a personal preference of mine, it feels like because we have reached a threshold of how effective psychotherapy can be (common factors argument). To me, it feels like more tangible and real-world issues such as treatment retainment, expansion of services, and how to reduce cost and increase accessibility would do better in achieving broad goals of clinical psychology. Regardless, this model showed that CPT seems to work through decreasing hopelessness, which then leads to intraindividual change in PTSD. Although I don't love the idea of these studies, this was well run in terms of the statistical modeling and mediation. Also, I am wondering about how much we care about mechanisms if two things produce the same outcome. If certain therapists are more comfortable with doing one, it feels like they can (and are) both used to treat PTSD. Lastly, I think determining the specific treatment for someone (PE vs CPT) should be determined on specific case formulation factors such as somatic complaints, interpersonal need, cognitive schemas, history, cultural values, etc. Therefore, I do not think it is an issue that both of these exist, and it could be useful to have multiple evidence based treatments for an issue. 

The Resick et al. (2016) CPT manual was really cool, I enjoyed reading through the worksheets, therapist guide, and steps of the therapy. Unlike many other theories, CPT seems to have a straightforward way of conducting it, evidenced by the emphasis on a full recap of each step of CPT at the end of the 12 weeks and the certificate given to clients. There are also a lot of good materials in here about how they engaged with homework materials, measures of symptoms over time (PCL-5), and worksheets that clients can use between sessions to practice. Compared to a therapy like ACT, many of these worksheets seemed more straightforward, perhaps because cognitions and tracking behaviors are slightly easier to grasp than ideas such as acceptance and cognitive flexibility. Therefore, I can see how an approach like this would be intuitive for clients, especially because many of the worksheets seem to be set up in an academic-type manner (do this homework for next week and I will assess it). I also really liked the stuck point help sheet (pdf p. 33), for it emphasized what a stuck point is and is not, and focused on how clients can identify them. It also feels like a good therapy that if a client does get confused or stalled at a certain point, these materials feel like very tangible reminders of what the client has accomplished and done so far. This might be especially helpful for patients who have experienced memory issues or TBIs. 

The Beck & Haigh (2014) chapter discusses the generic cognitive model (GCM) and its applicability to a variety of mental health disorders, as it explains that understandings of concepts like schemas, beliefs, modes, processing, and attention can explain and be used in the treatment of all mental disorders. This piece thoroughly described the important parts of cognition in relevance to psychopathology, and did a good job of distinguishing cognitive psychology principles (attention, memory) from the cognitive elements they were talking about. In this piece, I liked their explanation of schemas, how although they are not really a thing we can see, they are useful to be measured by the impermeability, density, and global applicability for the person. This was a useful criterion for me, for I often feel like naming out the schemas is unhelpful, for they can be adaptive or maladaptive depending on the context. Specifically, I can see how these beliefs may apply to disorders like anxiety or OCD where the beliefs are not necessarily wrong, just blown out of proportion and therefore causing distress. In addition, I liked how this model explained challenging client thoughts and beliefs. Maybe it is due to the word 'challenge', but I have seen cognitive therapies described as sometimes adversarial to client experience, which is not true, but may be a critique. Here, however, the authors described how testing beliefs, schemas, and even behaviors against reality can simply increase insight by decreasing the scope and importance of a schema for a client. Throughout many of these articles, I was interested with how they described emotions as secondary, focusing on them as sources of information, signals, or consequences that led to distress. This is obviously very different than a theory like EFT would understand emotions, and if these two theories have comparable efficacy, I would be interested in understanding why. One good technique the authors suggested that I will probably use is the idea of examining conditional beliefs held by the patient (if I get this job, I am the best), and specifically asking the client what thoughts and feelings would occur each direction. This seems like a good tool for promoting insight. In all of these readings, the authors talk a lot about setting emotions and such against reality.  While this seems like a good strategy in cases like PTSD, I wonder how it would be in the therapy room to see emotions as secondary signals for a disorder like borderline personality disorder where a focus on rational cognitions may feel invalidating. Overall, I think cognitive theory draws on a sound base of literature and has a very nice integrating framework. I do think, however, it has an advantage of being meta. Often when we think about emotions, somatic feelings, or even behavior, there is a layer of issues with operationalization, fuzzy constructs, or disagreement on the why or the black box. Cognitive theories get the unique and weird advantage of being able to think about thoughts, and because both clinicians and clients are intimately familiar with problem solving and critical thinking, it sounds much more intuitive than a somatic based therapy. Thinking about how we think about thoughts is also meta, but I think it serves us a good language of communication as well that some other theories lack because they lack clear constructs. 

Grade: 25/25