Applying Standard CT with Jarrad

I was asked for suggestions about how to apply "standard" CT with someone like Jarrad... Actually, from the information we've been given it sounds like a good start has already been made.

First, let me be clear about what I mean by "standard" CT. Here is my understanding of the Basic principles of CT:

• 1. Collaborative Empiricism. The therapist endeavors to work collaboratively with the client to help him or her to recognize the factors that contribute to problems, to test the validity of the thoughts, beliefs, and assumptions which prove important, and to make the necessary changes in cognition and behavior. By actively collaborating with the client, the therapist minimizes resistance and oppositionality. Explicit testing of cognitions, often via "behavioral experiments", rather than simply analyzing them logically is often much more convincing than any amount of intellectual insight
• 2. The therapist takes an active, directive role. The therapist actively structures each session and the overall course of therapy in an effort to use the time efficiently and effectively. The therapist also tries to maximize the client's involvement in therapy through an emphasis on a process of "guided discovery" in which therapist guides the client by asking questions, making observations, and asking the client to monitor relevant aspects of the situation. In this way the therapist helps the client develop an understanding of the problems, explore possible solutions, develop plans for dealing with the problems, and implement the plans effectively .
• 3. Interventions are based on an individualized conceptualization. A strategic approach to intervention is emphasized in which therapist uses a clear conceptualization of the client's problems as a basis for selecting the most productive targets for intervention and the most appropriate intervention techniques.
• 4. The focus is on specific situations and specific thoughts, feelings, and actions. Collecting detailed information and analyzing of specific problem situations, rather than simply talking about the problems in general, makes it easier to develop an understanding of the client's problems and to develop effective interventions.
• 5. Focus on modifying thoughts, coping with emotions, and/or modifying behavior as needed. Cognitive Therapy is a "technically eclectic" approach in that a wide range of intervention techniques can be used flexibly within a coherent conceptual framework . While cognitive-behavioral interventions are used most frequently, the full range of therapeutic techniques can be used as long as they are appropriate to the goals being pursued at the moment, are compatible with the conceptualization of the client's problems, and are used collaboratively.
• 6. The client continues the work of therapy between sessions. "Homework assignments" are used extensively throughout Cognitive Therapy . Not only does this increase the amount of time spent actively attempting to overcome problems, but in addition clients have the opportunity to collect data in the actual situations where their problems occur and to test the effects of cognitive and behavioral changes in daily life. Those clients who complete self-help assignments at least half of the time have been shown to both respond to treatment more quickly and achieve better results .
• 7. Later interventions focus on predisposing factors. Modifying a client's dysfunctional automatic thoughts and maladaptive interpersonal behavior might, in theory, be sufficient to alleviate the client's immediate distress. However, if this is all that is done in therapy, the client could be prone to relapse when he or she encounters situations which activate dysfunctional schemas. In the later stages of therapy, the therapist actively attempts to identify and modify dysfunctional schemas and any other factors which would otherwise predispose the individual to relapse.
• 8. Therapist and client explicitly plan to prevent relapse. In theory, effectively modifying the client's basic assumptions and any dysfunctional interaction patterns should leave him or her no more prone to future problems than anyone else. However, it is often hard for a therapist to gauge whether interventions have been completely effective. Therefore, Cognitive Therapy ends by explicitly working to prepare the client to deal with future set-backs. This work, based on Marlatt and Gordon's research on relapse prevention, consists of helping the client to become aware of high-risk situations, to identify early warning signs of impending relapse, and to develop explicit plans for handling high-risk situations and heading off potential relapse.

It sounds like Jarrad's treatment thus far has incorporated most of these principles. Obviously, the automatic thoughts which were identified in group provide an opportunity for one of the best-known "standard" interventions, using guided discovery to challenge dysfunctional cognitions:

• "[crime is] easy money" - Does his experience indeed show this to be true? Overall, how financially lucerative has his criminal activity been? Does he have any acquaintainces who chose legal methods of acquiring money? If so, are they better-off or worse-off than he is? Is there a more realistic alternative view? (Maybe something like "Crime looks like easy money but it doesn't work out that way in the long run.")
• "[crime] is fun, exciting" - Is it true that crime has consistently been fun and exciting for him? Does crime have drawbacks that outweigh the fun and excitement? Are there other activities which are fun and exciting but don't have the drawbacks that crime does?
• "I can't stand to be told what to do." - Is this true or would it be more accurate to say "I'm not willing to tolerate being told what to do."? What are the drawbacks of choosing to tolerate being told what to do (looking at a concrete example or two)? Are there any advantages to being able to sometimes tolerate being told what to do?
• "People aren't any good if they don't see it my way." "If people don't see it my way, they're out to get me." - Is this true? Suppose there's a time when I don't see it your way... does that mean I'm no good or out to get you? Would I be more useful as a therapist if I always saw it your way? If I always saw it your way how could I help you change?
• "Others need to suffer for what they've done to me." - Is this so? Suppose they aren't suffering... is it a good idea to try to make them suffer? Suppose I succeed in making them suffer... what is it supposed to accomplish? Does it really work out that way? Are there drawbacks to trying to make people suffer?

"Rational Responses" alone aren't adequate, of course. The interventions described in the case presentation (i.e. stop and think, pleasant imagery, time-out, problem-solving skills, etc.) sound quite promising. With this population I often spend a lot of my time early in therapy working to improve means-ends thinking, to identify more adaptive behavior and put it into practice, and to improve impulse control.

Stay tuned for more when I have time.

Replies:

Update on Jarrad, by Linda Nauth (e-mail , 4/20/98 Dealing with Jarrad's Thoughts of Harming Self/Others, by Jim Pretzer, 4/20/98 Re: Applying Standard CT with Jarrad, by Linda Nauth, 4/24/98

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