Final Paper
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CognitiveTheoryChapter.docxCognitive Theory
The brain is wider than the sky, For, put them side by side, the one the other will include with ease, and you beside. The brain is deeper than the sea, For, hold them, blue to blue, the one the other will absorb, as sponges, buckets do. *
You are driving down the interstate, 10 miles over the speed limit. Suddenly you see flashing lights and hear the siren of a police car behind you. How do you feel? Scared! You pull over. The police car proceeds to follow the car that was in front of you. Now you feel relieved, even happy. What changed? The police car was always following the car in front of you. What changed was the nature of your thoughts about what you had observed. Many behavioral practitioners eventually turned their attention to clients’ internal interpretations of events as they respond to stimuli and reinforcers. Social learning theory (Bandura, 1977) was instrumental in developing the concept of cognitive mediation, defined as the influence of one’s thinking between the occurrence of a stimulus and response. Learned patterns of evaluating environmental stimuli help to explain why each of us adopts unique behaviors in response to similar stimuli. This and other developments in the cognitive sciences (described below) accounted for the development of cognitive theory in social work practice. This approach is consistent with behaviorism in many ways and, as we shall see, the two theories can be used together
Cognitive theory for clinical practice emerged in the 1960s and continues to be a popular and effective basis for intervention by social workers. It is quite different from the ego and relational theories in its assertion that conscious thinking is the basis for most human behavior and emotional experience. It is different from behavioral theory in its focus on internal mental processes. Whereas some of these processes might be categorized as unconscious (or preconscious), they are presumed to maintain a minor influence on behavior and can readily be brought to the surface with reflection or the social worker’s probing (Lantz, 1996).
Cognitions include our beliefs, assumptions, expectations, and ideas about the causes of events, attitudes, and perceptions in our lives. Cognitive theory postulates that we develop habits of thinking that form the basis for our screening and coding of environmental input, categorizing and evaluating that experience, and making judgments about how to behave. Emotions are defined within this theory as physiological responses that follow our cognitive evaluation of input (Lazarus & Lazarus, 1994). Thus, thoughts occur prior to most emotions, and, in fact, produce them.
The relationship between thoughts, feelings, and behaviors can be summarized as follows (Beck, 1995):
An activating event—produces a belief or thought—that produces an emotion or action.
Cognitive interventions are focused on enhancing the rationality of a client’s thinking patterns, the degree to which conclusions about the self and the world are based on external evidence, and the linear connections among a person’s thoughts, feelings, and behaviors.
ORIGINS AND SOCIAL CONTEXT
Cognitive theory is consistent with trends in American thought that have existed since the late 1800s. It did not work its way into the helping professions, how- ever, until the 1950s. Its influences included developments in American philosophy, information processing theory in the computer sciences, and social learning theory in psychology.
Pragmatism and Logical Positivism
American philosophers have always tended to evaluate ideas pragmatically, with reference to practical applications, compared to their European cohorts (Kurtz, 1972). One example is John Dewey (1938), the most influential American pragmatist of the early 20th century who, as described in Chapter 3, also influenced the development of person-centered theory. He wrote that when a person’s experiences present challenges to understanding, the natural response is to initiate a process of problem solving, or “inquiry.” Dewey maintained that ideas are arrived at through plans of action that are evaluated for “truth” by their expected consequences. His work influenced the systematic procedures seen in the problem-solving model, described later in this chapter. Logical positivism was an- other major philosophical movement that became prominent in the United States in the 1930s (Popper, 1968). Focused on language, the positivists perceived the task of philosophy to be analysis and clarification of meaning, and they looked to logic and the sciences as their models for constructing formally perfect languages. The positivists’ verifiability principle maintained that a statement was meaningful only if it was empirically verifiable. They were critical of ideas that could not be tested, and these ideas influenced theorists from other fields who became concerned with verifiability.
Information Processing Theory
The advance of computer and information technology was particularly influential on the development of a “science of cognition” in the social sciences (Bara, 1995). Human service practitioners became interested in how people processed information and in correcting cognitive “errors.” In retrospect, these ideas may seem like rather simplistic accounts of how the mind works, but they emerged at a time when little was understood about the functioning of the nervous system.
Information processing theory maintains that there is a clear distinction be- tween the thinker and the external environment (Ingram, 1986). People receive stimulation from the outside and code this with sensory receptors in the nervous system. The information is then integrated and stored for the purposes of present and future adaptation to the environment. We develop increasingly sophisticated problem-solving processes through the evolution of cognitive patterns that enable us to attend to particular inputs as significant. Information processing is a sensory theory in that information from the external world flows passively inward through the senses to the mind. The mind is viewed as having distinct parts, including a sensory register, short-term memory, and long-term memory, which make unique contributions to our thinking in a specific sequence.
Information processing theory eventually gave way to motor theories, in which the mind is thought to play an active role in processing input, not merely recording but also constructing its nature. This was augmented, in turn, by models of the mind as engaging in parallel processes, organizing multiple activities in perception, learning, and memory while it receives external information. That is, the mind is interactive with its environment.
Personal Construct Theory
The American psychologist George Kelly introduced a theory of personality in 1955 in which a person’s core tendency is to attempt to predict and control the events of experience (Maddi, 1996). He described the essence of human nature as the scientific pursuit of truth—an engagement in empirical procedures of formulating hypotheses and testing them in the tangible world. This “truth” is not absolute but represents a state in which perceptions are consistent with our internal construct system. Constructs are interpretations of events arrived at through natural processes of reasoning. Kelly asserted that the only important difference between laypersons and professional scientists is that the latter are more self-conscious and precise about their procedures.
Kelly’s model of the “person as empirical scientist” influenced the ideas of cognitive theorists who followed him. These included Leon Festinger and cognitive dis- sonance theory, Seymour Epstein’s hierarchical organizations of personal constructs, and David McClellan’s explorations of motives, traits, and schemas. All of these theorists, in turn, had direct influence on the psychotherapies of Albert Ellis and Aaron Beck.
Albert Ellis and Aaron Beck
Albert Ellis was the first cognitive therapist, publishing Reason and Emotion in Psychotherapy in 1962. He believed that people can consciously adopt principles of reasoning, and he viewed the client’s underlying assumptions about himself or her- self and the world as targets of intervention. The major theme of Ellis’s work is that our understandings of how we need to conduct ourselves to maintain security are often narrow and irrational. Behind most distressing emotions, one can find irrational beliefs about how things should or must be. Ellis’s therapy involved helping people become more “reasonable” about how they approached their problems. He was known to be a confrontational practitioner, actively persuading clients that some of the principles that they lived by were arbitrary and unrealistic.
Cognitive therapy became a more prominent practice theory with the publication of Aaron Beck’s Cognitive Therapy and the Emotional Disorders in 1976. Beck had been trained as a psychoanalyst and was interested in the problem of depression. He initially attempted to validate Freud’s theory of depression as “anger turned toward the self.” Instead, his observations led him to conclude that depressed people maintain a negative bias in their cognitive processing. He conceptualized this negativism in terms of cognitive schemas—memory structures made up of three basic themes of personal ineffectiveness, personal degradation, and the world as an essentially un- pleasant place. Beck was less confrontational than Ellis, seeing clients as “colleagues” with whom he examined the nature of “verifiable” reality.
In the past 50 years, many cognitive practitioners have integrated techniques from cognitive theory with strategies from other approaches. As one prominent ex- ample, Meichenbaum’s work (1977) combined cognitive modification and skills training in a therapy model that is useful in treating anxiety, anger, and stress.
Cognitive Theory in Social Work
Social workers have been using cognitive theory extensively for more than 30 years. Reid and Epstein’s (1977) Task-centered Practice, while not strictly cognitive in theoretical orientation, incorporated many elements of the structured, rational, behavioral-outcome-focused intervention that characterize the approach. The following year, Lantz (1978) published a comprehensive summary of cognitive theory and its related interventions in Social Work. In 1982 Sharon Berlin began her work integrating the theory with the unique perspective of the social work profession, which culminated in her book Clinical Social Work Practice: A Cognitive-Integrative Perspective in 2002. Berlin’s work addresses a gap in the literature on cognitive therapy that stems from its almost exclusive focus on personal meanings and lack of attention to the ways people acquire information from their social environments. That is, cognitive therapy approaches in social work must in- corporate clients’ life conditions and interpersonal events, particularly those who experience severe deprivation, threats, and vulnerability. More recently, Corcoran (2005), in Building Strengths and Skills: A Collaborative Approach to Working with Clients, constructed an eclectic practice approach for social workers that interweaves both strength-based and skills-based practice approaches through a creative integration of motivational interviewing, solution-focused therapy, and cognitive- behavioral therapy.
MAJOR CONCEPTS
Within cognitive theory there are no assumed innate drives or motivations that propel people to act in particular ways. We all develop patterns of thinking and behavior through habit, but these patterns can be adjusted as we acquire new in- formation. A central concept in cognitive theory is that of the schema, defined as our internalized representation of the world, or patterns of thought, action, and problem solving (Granvold, 1994). Schemas include the ways that we organize thought processes, store information, process new information, and integrate the products of those operations (knowledge). Schemas are the necessary biases with which we view the world, based on our early learning. They develop through direct learning (our own experiences) or social learning (watching and absorbing the experiences of others). When we encounter a new situation, we either assimilate it to “fit” our existing schema, or accommodate it, changing the schema if, for some reason, we can’t incorporate the experience into our belief patterns. A flexible schema is desirable, but all schemas tend to be somewhat rigid by nature.
Piaget’s (1977) theory of cognitive development is the most influential in social work and psychology. It describes the first schema that an infant possesses as a body schema, because a small child is unable to differentiate between the self and the external world. Cognitive development involves a gradual diminishing of this egocentricity. In Piaget’s system, the capacity for reasoning develops in stages, from infancy through adolescence and early adulthood. These stages are sequential, evolving from activity without thought to thought with less emphasis on activity. We evolve from being toddlers who scream out when hungry, to adults who patiently prepare our own meals. That is, cognitive behavior evolves from doing to doing knowingly, and finally to conceptualization. Normal maturation in one’s physical and neurological development is necessary for full cognitive development.
Figure 8.1 illustrates how our core beliefs (schemas) influence the manner in which we perceive particular situations throughout life. Our internal perspectives about the world, based on unique life experiences, lead to assumptions and related coping strategies. These core beliefs have a direct influence on how we perceive and react to life situations. Our assumptions and related strategies are not “correct”
Relevant Early Life Experiences
For example: Negative comparison of self with siblings
Core Beliefs/Schemas (pervasive and rigid, but changeable)
Fundamental assumptions regarding the self, others, the world, the future When problematic, these involve themes of helplessness or unlovability “I don’t have qualities that can attract other people.” “I’m not capable of being successful.”
Coping Assumptions
May be constructive or destructive “If I work hard, I can do well.” “If I don’t do great, then I am a failure.”
Coping Strategies
For example: High standards, hard work, correct shortcomings (positive) Over-preparation, manipulation, avoid seeking help (negative)
Specific Situations
(For example, performance in graduate school)
Thoughts and Their Meanings
(May be constructive or destructive) “I can get through this if I go to every class and do all the reading.” “I can’t do all this work. I don’t have the energy.”
Emotions
Pride, excitement Depression, guilt
Behaviors
Organizing a study schedule Cheating, quitting
F I G U R E 8.1 The Influence of Core Beliefs
or “incorrect” as much as they are “functional” or “non-functional” for our ability to achieve our goals. Schemas can change, but not always easily.
It was mentioned earlier that cognitive theory is a motor theory, asserting that we do not merely receive and process external stimuli, but are active in constructing the reality we seek to apprehend. There is no singular way to perceive reality; still,
rational thinking can be understood as thinking that (Ellis & McLaren, 1998):
Is based on external evidence Is life-preserving Keeps one directed toward personal goals
Decreases internal conflicts
A person’s thoughts can accurately reflect what is happening in the external world or be distorted to some degree. These distortions, called cognitive errors, will be described below.
Cognitive interventions are applicable to clients over the age of approximately 12 years because the person must be able to engage in abstract thought. Of course, some adults with cognitive limitations, such as intellectual developmental disability, dementia, and some psychotic disorders, may not be responsive to the approach. To benefit from these interventions, clients must also be able to follow through with directions, not require an intensely emotional encounter with the social worker, demonstrate stability in some life activities, and not be in an active crisis (Lantz, 1996).
Other concepts that are central to cognitive theory will be introduced in the section below.
THE NATURE OF PROBLEMS AND CHANGE
Many problems in living result from misconceptions—conclusions that are based more on habits of thought rather than external evidence—that people have about themselves, other people, and their life situations. These misconceptions may develop for any of three reasons. The first is the simplest: The person has not acquired the information necessary to manage a new situation. This is often evident in the lives of children and adolescents. They face many situations at school, at play, and with their families that they have not experienced before, and they are not sure how to respond. This lack of information is known as a cognitive deficit and can be remedied with education. A child who has trouble getting along with other children may not have learned social skills and teaching that child about social expectations may help to resolve the problem.
The other two sources of misperception are rooted in schemas that have be- come too rigid to manage new situations. That is, the schema cannot accommodate the situation. An adolescent who can manage conflicts with his friends suddenly realizes that he cannot use those same strategies to manage conflict with his new girlfriend.
As a part of one’s schema, causal attributions refer to three kinds of assumptions that people hold about themselves in relation to the environment. First, a person might function from a premise that life situations are more or less change- able. (I’m unhappy with my job, and there is nothing I can do about it.) Second, a person may believe that, if change is possible, the source of power to make changes exists either within or outside the self. (Only my supervisor can do
something to make my job better.) Finally, a person might assume that the implications of his or her experiences are limited to the specific situation, or that they are global. (My supervisor didn’t like how I managed that client with a substance abuse problem. He doesn’t think I can be a good social worker.)
The final sources of misperceptions are specific cognitive distortions of reality. Because of our tendency to develop thinking habits, we often interpret new situations in biased ways. These patterns are generally functional because many situations we face in life are similar to previous ones and can be managed with patterned responses. These habits become a source of difficulty, however, when they are too rigid to accommodate our considering new information. For example, a low-income community resident may believe that he lacks the ability to advocate for certain medication benefits and, as a result, continues to live with- out them. This belief may be rooted in a distorted sense that other people will never respect him. The client may have had real difficulties over the years with failure and discrimination, but the belief that this will happen in all circumstances in the future may be arbitrary. Table 8.1 lists some widely held cognitive distortions, also known as “irrational beliefs” (Beck, 1967), with examples.
T A B L E 8.1 Common Cognitive Distortions
Irrational Beliefs
Arbitrary inference: Drawing a conclusion about an event with no evidence, little evidence, or even contradictory evidence
Selective abstraction: Judging a situation on the basis of one or a few details taken out of a broader context
Magnification or minimization: Concluding that an event is either far more significant, or far less significant, than the evidence seems to indicate
Overgeneralization: Concluding that all instances of a certain kind of situation or event will turn out a particular way because one or two such situations did
Personalization: Attributing the cause, or accepting responsibility for, an external event without evidence of a connection
Dichotomous thinking: Categorizing experiences as one of two extremes: complete success or utter failure (usually the latter)
Examples
” I’m not going to do well in this course. I have a bad feeling about it.” “The staff at this agency seem to have a different practice approach than mine. They aren’t going to respect my work.”
“Did you see how our supervisor yawned when I was describing my assessment of the client? He must think my work is superficial.”
“I got a B on the first assignment. There is a good chance I will fail this course.” “I don’t really need to get to work on time every day. My clients don’t seem to mind waiting, and the administrative meeting isn’t relevant to my work.”
“My supervisor thinks that my depressed client dropped out because I was too confrontational. I don’t have enough empathy to be a decent social worker.”
“The instructor didn’t say this, but our group presentation got a mediocre evaluation be- cause of my poor delivery.”
“I didn’t get an A on my final exam. I blew it! I’m not competent to move on to the next course.” “I got an A on the midterm. I can coast the rest of the way through this course.”
Interventions within cognitive theory can help clients change in three ways. Clients can change their personal goals to become more consistent with their capabilities, adjust their cognitive assumptions (beliefs and expectations), or change their habits of thinking (which includes giving up cognitive distortions). Even when some of a person’s beliefs are distorted, the potential to correct them in light of contradictory evidence is great. During assessment, the social worker observes the client’s schema, identifies thinking patterns with respect to the presenting situation, and considers the evidence supporting the client’s conclusions about the situation. When those conclusions seem valid, the social worker helps the client develop better problem-solving or coping skills. When the conclusions are distorted, the social worker uses techniques to help the client adjust his or her cognitive processes in ways that will facilitate goal attainment.
ASSESSMENT AND INTERVENTION
The Social Worker/Client Relationship
Cognitive intervention is always an active process. Intervention often resembles a conversation between the social worker and the client. (I often tell students that if they like to talk, this is a good theoretical perspective to adopt.) The social worker serves as an educator in situations where clients experience cognitive deficits, and as an “objective” voice of reason (to the extent that this is possible) when the client experiences cognitive distortions.
The practitioner is a collaborator—goals, objectives, and interventions are developed with the client’s ongoing input. The client’s desired outcomes are often written down so that they may be followed consistently over time or re- vised. Beyond this, the social worker may serve as a model of rational thinking and problem solving for the client, or as a coach, leading the client thorough a process of guided reasoning. The social worker needs to demonstrate empathy with the client’s problem situation, in part because confrontation is frequently a part of the interventions. Confrontation involves the social worker pointing out discrepancies between a client’s statements and actions (Hepworth, Rooney, Rooney, Strom-Gottfried, & Larsen, 2012), which can sometimes be difficult for a client to tolerate. The social worker’s perceived positive regard will help the client understand that these confrontations are being presented constructively.
Cognitive interventions are highly structured, and it is the responsibility of the social worker to establish and maintain that structure (Beck, 1995). The structure of the first session includes the social worker’s setting an agenda, doing a mood check, reviewing and specifying the presenting problem, setting goals, educating the client about the cognitive model, eliciting the client’s expectations for the intervention, educating the client about the nature of his or her problem, setting up homework assignments, providing a session summary, and eliciting the client’s feedback about the session. Subsequent sessions include brief updates and checks on the client’s mood, the social worker’s linking issues between the previous and current session, setting the agenda, reviewing homework, discussing issues on the agenda, setting up new homework tasks, providing a final session summary, and eliciting the client’s feedback about the session.
The social worker must always be aware that his or her assessments are also subject to cognitive biases. To minimize the possibility of his or her own distortions when working with a client, the social worker should:
Consistently examine his or her own beliefs and attitudes about the client through supervision
Generate and evaluate a variety of hypotheses about a client’s problem situation Consider and “rank” the evidence for and against the “working hypotheses”
about a client Use clear evaluation measures of client change (standardized or personalized) Use various sources of feedback, including peers and supervisors
Assessment
The practitioner initially educates the client in the logic of cognitive theory and then assesses the client’s cognitive assumptions, identifying any distortions that may con- tribute to problem persistence. The rationality of a client’s thinking is assessed through a process known as Socratic questioning (Boyle, Hull, Mather, Smith, & Farley, 2009). This term derives from the work of the philosopher Socrates, whose teaching technique involved asking questions of his students until they came upon the answers by themselves. The social worker assesses the validity of a client’s assumptions associated with a problem issue through detailed, focused questioning. After the client describes the presenting problem and some of the relevant history surrounding it, the following types of questions guide the social worker’s assessment:
First, tease out the client’s core beliefs relative to the presenting problem (“What were you thinking when...?” “How did you conclude that...?” “What did it mean to you when...?”)
What is the logic behind the client’s beliefs regarding the significance of the problem situation?
What is the evidence to support the client’s views? What other explanations for the client’s perceptions are possible?
How do particular beliefs influence the client’s attachment of significance to specific events? Emotions? Behaviors?
To maximize the reliability of the client’s self-reports during assessment and intervention, the social worker should (Berlin, 2002):
Inquire about a client’s cognitive events of concern as soon as possible after the event
Analyze the internal consistency of a client’s statements
Minimize the kind of probing that may influence a client’s ability to reflect
“objectively” on his or her thoughts and feelings
Help the client acquire cognitive retrieval skills (through imagery and relaxation)
At the end of the assessment, the social worker helps the client to arrive at a tentative conclusion about the rationality of his or her thought patterns, and, if any distortions are apparent, examines the client’s willingness to consider alternative perspectives.
Intervention
When a client’s perceptions and beliefs seem valid, the practitioner intervenes by providing education about the presenting issue and implementing problem- solving or coping exercises. When the client exhibits significant cognitive distortions, the practitioner and client must identify the situations that trigger the mis- conceptions, determine how they can be most efficiently adjusted or replaced with new thinking patterns, and then implement corrective tasks. Various specific intervention strategies are presented below. Not all possible interventions are described in this chapter (there are many), but what follows is representative of the theory.
Cognitive Restructuring Strategies for cognitive intervention fit into three general categories. The first of these is cognitive restructuring. This technique is used when the client’s thinking patterns are distorted and contribute to problem development and persistence (Mueser, Rosenberg, & Rosenberg, 2009). Through a series of discussions and exercises, the social worker helps the client experiment with alternative ways of approaching challenges that will promote goal attainment.
The ABC model (presented earlier in this chapter) is the basis of the cognitive restructuring approach. “A” represents an activating event; “B” is the client’s belief about, or interpretation of, the event; and “C” is the emotional and behavioral consequence of B. For example, if A is an event (a rainy day) and C, the consequence, is the person’s feeling of depression, then the B (belief) might be: “Everything looks so gray and ugly, and I wanted to go out. Nothing can go well for me on a day like this.” If the same activating event (rain) occurs, but the resulting emotion (consequence, or C) is contentment, the client’s belief might be: “How peaceful. Today I can stay home and read. It’ll be really cozy.” The ABC process occurs so quickly that clients often make the assumption that A directly causes C, but except in certain reflexive actions (such as placing a finger on a hot stove and then abruptly pulling it back), there is always a cognitive event, B, that intervenes.
In order to change a client’s belief systems, three steps are necessary. The first is to help the person identify the thoughts preceding and accompanying the distressing emotions and non-productive action (“What was going through your mind...?”). It is important to put the client into a frame of mind in which he or she can reflect on thoughts and feelings as if the event is occurring at the present
moment. Some clients may require assistance in grasping their thinking patterns. The practitioner might engage the client in imagery (“Close your eyes, take a deep breath, and see yourself in that situation. What are you doing? What are you feeling? What are you thinking?”). The social worker may invite other clients to participate in role-plays toward the same end (“Let’s pretend we’re at work, and I am your boss...”). By reenacting the problem situation, clients can more accurately retrieve the thought patterns contributing to the problem.
The second step is to assess the client’s willingness to consider alternative thoughts in response to the problem situation. One means of addressing this is the point/counterpoint or cost/benefit analysis, in which the social worker asks the client to consider the costs and benefits of maintaining his or her current beliefs pertaining to the problem (Leahy, 1996). This can be accomplished through simple conversation, but is often more effective with pen and paper. Writing down the pros and cons of an argument can help the client visualize whether his or her goals are being well served by the current perspective. It must be emphasized that the mere number of pros and cons will not influence the client’s thinking in one direction or the other, as some will carry more “weight” than others.
The ABC Review
This cognitive intervention technique requires a client to fill out a form over a specified period of time (Hofmann & Reinecke, 2010). Its purpose is to help the client become more aware of his or her automatic thoughts and subsequently work toward modifying them so that emotions and behaviors can become more productive. Following an assessment of the client’s cognitive patterns, the social worker prepares a sheet of paper with four columns (see Figure 8.2). The first column is headed “Situation that produces stress” (the A component of the ABC process). The client is instructed to write down during the course of a day the situations that produce the negative emotions or behaviors for which he or she is seeking help. The next column is headed “Automatic thought” (the B component), and here the client records the thoughts that accompany the situation. This step is difficult and takes practice for many clients. Some tend to overlook their interpretations that intervene between situations and emotional and behavioral responses. Others tend to record emotions rather than thoughts. During the intervention, the social worker can help the client learn to distinguish between thoughts and feelings. Next, the client is asked to think about and record in the third column the assumptions that seem to underlie the automatic thought. For example, a client who is rejected for a job (the situation) may think that he “will never get a good job” (automatic thought) because “I am worthless” (the underlying assumption).
Finally, the client is asked to record the emotional response to the automatic thought, such as depression or panic (the C component).
The social worker asks the client to fill out the form with some mutually agreed-on frequency, depending on the nature of the problem and the ability of the client to maintain a structured task focus. Often, the social worker will ask the client to fill out the form every day between their meetings, when they can review it together. Over time, the social worker helps the client clarify his or her automatic thoughts and understand which of them are arbitrary. The social worker then asks the client, with an expanded form, to experiment with alterna- tive, more rational thoughts about his or her problem situation that might be more constructive (see Figure 8.2 again). These alternative thoughts, and the feelings that follow them, can be written in fourth and fifth columns on the page. The client and social worker can then monitor how the client’s feelings and behaviors change.
Cognitive Coping
A second category of interventions is cognitive coping. The practitioner helps the client learn and practice new or more effective ways of dealing with stress and negative moods. All of these involve step-by-step pro- cedures for the client to master new skills. (Here we begin to see the conver- gence of the cognitive and behavior theories: combining new thinking patterns with new situations that may provide reinforcement of new behaviors.) Cog- nitive coping involves education and skills development that targets both co- vert and overt cognitive operations, with the goal of helping clients become more effective at managing their challenges. Clients can modify their cognitive distortions when they experience positive results from practicing new coping skills. That is, if clients develop good coping skills, they may elicit positive reinforcement from the environment. Several interventions are presented here in detail.
Self-Instruction Skills Development
This is a means of giving clients an internal cog- nitive framework for instructing themselves on how to cope more effectively with problem situations (Kunzendorf et al., 2004; Meichenbaum, 1999). It is based in part on the premise that many people, as a matter of course, engage in internal speech, giving themselves “pep talks” to prepare for certain challenges. For exam- ple, one good friend of mine, a respected social worker, stands in front of the mir- ror every morning and lectures herself about what she needs to do to manage the most difficult parts of her workday. She feels energized by this practice.
Often, when people find themselves in difficult situations that evoke tension or other negative emotions, their thinking may become confused, and their ability to cope diminishes. Some people have a lack of positive cues in their self-dialogue. Having a prepared internal (or written) script for problem situations can help a client recall and implement a coping strategy. When using this technique, the so- cial worker assesses the client’s behavior and its relationship to deficits in sub-vocal dialogue. The client and social worker develop a self-instruction script, including overt self-directed speech, following their plan for confronting a problem. Such a script may be written down or memorized by the client. The social worker and client visualize and walk through the problem situation together so the client can rehearse its implementation. During rehearsal, the client gradually moves from overt self-dialogue to covert self-talk. The client then uses the script in the natural environment, either before or during a challenging situation.
As an example, Beth (who will be introduced later in more detail) felt guilty about dropping her young son off at the day care center every morning on her way to classes, believing that she was a poor mother for indulging herself at the expense of time with her son. This negative feeling stayed with her much of the day. She developed a self-instruction script with the social worker that included the follow- ing statements: “My son will be well cared for. Many good parents take their chil- dren to day care when they go to work every day. I spend every evening and every weekend with my son. When I get my degree, I will be a better provider for my son and myself. It is good for my son to learn to interact with other people. He has a chance to play with other children while there. I will be a better parent if I take care of myself as well as him.” Beth initially wrote down these statements, but quickly memorized them. She recited them to herself internally every morning and anytime during the day that she began to feel guilty about her son.
Communication Skills Development
The teaching and rehearsal of these skills cover a wide spectrum of interventions that includes attention to clients’ social, assertiveness, and negotiation skills. Positive communication builds relationships and closeness with others, which in turn helps improve mood and feelings about oneself (Hepworth et al., 2012; Hargie, 1997). Social support is a source of posi- tive reinforcement and buffers individuals from stressful life events. In addition, when a person can articulate his or her concerns, other people may construc- tively suggest how that person might adjust his or her attitudes and behaviors.
The components of communication skills development include using “I” messages, reflective and empathic listening, and making clear behavior change requests. (These were discussed in Chapter 6, as an intervention with family emotional systems theory.) “I” messages are those in which a person talks about his or her own position and feelings in a situation, rather than making accusatory comments about another person. The basic format for giving “I” messages is: “I feel (the reaction) about what happened (a specific activating event).” For exam- ple: “I feel angry when you break curfew on Saturday night. I also worry about you.” These statements help the speaker to maintain clarity about his or her own thoughts and feelings. This is a clearer communication than saying, “How dare you stay out so late!” which generally makes the other person feel defensive.
Listening skills include both reflective listening and validation of the other person’s intent. The purpose of reflective listening is to ensure that one under- stands the speaker’s perspective. It decreases the tendency of people to draw pre- mature conclusions about the intentions and meaning of another’s statement (Brownell, 1986). Reflective listening involves paraphrasing the feelings and con- tent of the speaker’s message with the format: “What I hear you saying is...” or “You seem to feel [feeling word] when I...” Beyond reflection, validation in- volves conveying a message that, given the other person’s perspectives and as- sumptions, his or her experiences are legitimate and understandable (“I can see that if you were thinking I had done that, you would feel angry”).
A third component of communication skill development involves teaching people to make clear behavior requests of others. Such requests should always be specific (“Pick up your toys”) rather than global (“Clean up this room”), measurable (“I would like you to call me once per week”), and stated in terms of positive behavior rather than the absence of negative behavior (“Give me a chance to look at the mail when I come home” rather than “Stop bothering me with your questions”).
Problem-Solving Skills Development
The third intervention category is problem solving. This is a structured, five-step method for helping clients who do not experience distortions but nevertheless struggle with the problems that they clearly perceive. Clients learn how to produce a variety of potentially effective responses to their problems (Freeman, 2004). The first step is defining the problem that the client wishes to overcome. As the poet Emerson (1958) wrote, “a prob- lem well defined is a problem half solved.” Solutions are easier to formulate when problems are clearly delineated. During the process, only one problem should be targeted at a time.
The next step in problem-solving skills development involves the client and social worker’s brainstorming to generate as many possible solutions to a presenting problem as they can imagine. At this point, evaluative comments are not al- lowed, so that spontaneity and creativity are encouraged. All possibilities are written down, even those that seem impossible or silly. Some supposedly ridicu- lous ideas may contain useful elements on closer examination. It is important in this step for the social worker to encourage additional responses after clients de- cide they are finished. Clients often stop participating when a list contains as few as five alternatives, but when pressed they can usually suggest more.
The third stage of the problem-solving process involves evaluating the alterna- tives. Any patently irrelevant or impossible items are crossed out. Each viable al- ternative is then discussed as to its advantages and disadvantages. More
information about the situation may need to be gathered as a result of the work during this stage. For instance, information might be gathered about other agen- cies and resources (including other people in the client’s life) that can assist in making some of the choices more viable.
Choosing and implementing an alternative involves selecting a strategy for prob- lem resolution that appears to maximize benefits over costs. Although the out- come of any alternative is always uncertain, the client is praised for exercising good judgment in the process, and is reminded that making any effort to address the problem is the most significant aspect of this step. The social worker should remind the client that there is no guarantee that the alternative will succeed, and that other alternatives are available if needed.
During the following session, the social worker helps the client to evaluate the implemented option. If successful, the process is complete except for the important discussion about how to generalize problem solving to other situations in the client’s life. “Failures” must be examined closely for elements that went well in addition to those still needing work. If a strategy has not been successful, it can be tried again with adjustments or the social worker and client can go back to the fourth step and select another option.
Role-playing is an effective teaching strategy that can be used with all of the above interventions (Freeman, 2004). This involves the social worker first modeling a skill, then the worker and client rehearsing it together. Role-playing offers a number of advantages for intervention. First, the social worker demonstrates new skills for the client, which usually is a more powerful way of conveying information than verbal instruction. Second, by portraying the client in a role-play, the social worker gains a fuller appreciation of the challenges faced by the client. At the same time, the client’s taking on the perspective of another significant person in his or her life (family member, boss, or friend) allows the client to better understand the other person’s position. Assuming the roles of others also introduces a note of playfulness to situations that may have been previously viewed with grim seriousness.
SPIRITUALITY AND COGNITIVE THEORY
Unlike behavior theory, the concepts of cognitive theory can facilitate an under- standing of clients’ spirituality and promote their reflections on the topic. Re- member that spirituality refers here to a client’s search for, and adherence to, meanings that extend beyond the self. Cognitive theory emphasizes each person’s natural inclination to make sense of reality, and the idea that values can change through reflection and action. The theory further asserts that we are active par- ticipants in constructing our realities. Thinking represents our organized efforts to create meaning from personal experience.
In the context of cognitive theory, then, spirituality can be understood as the core beliefs (including values) that provide us with meaning and motivate our actions. Effective social functioning depends on our developing patterns of shared meaning with others, and thus we tend to seek out others who share our
deepest concerns. Cognitive deficits or distortions may contribute to a person’s disillusionment in striving for spiritual goal attainment. Interventions relevant to spirituality include Socratic questioning, which helps clients reflect on long-term goals and the significance of problem situations in that context. Any cognitive interventions that encourage a client’s reconsideration of ways of understanding and acting on challenges may be relevant to his or her spirituality.
An example may help to clarify these points. Terri was a grade school teacher with a clear commitment to helping children develop positive social and academic skills. Her strong values about children were related in part to a personal background in which she had felt unfairly demeaned. Along with this core value went a belief that she was socially incompetent, less intelligent, and less worthy of affection than other people. This core belief led to serious cogni- tive distortions in which Terri believed herself to be untalented and inept profes- sionally. Acting on these distortions, Terri received unsatisfactory evaluations from the school principal and was at risk of losing her job. While the social worker helped Terri address her distortions with cognitive intervention strate- gies, he also helped her to maintain a focus on her ultimate value so that she would persist toward her goal of success in the classroom.
ATTENTION TO SOCIAL JUSTICE ISSUES
Cognitive theory includes many features that may facilitate the social worker’s pro- motion of social justice activities with clients. The theory incorporates an empower- ment approach, with its premise that people can be competent problem solvers, and can be helped to generalize problem-solving strategies to other life challenges. In examining core beliefs, the social worker will likely encourage the client’s examina- tion of personal and social values. The concept of “social construction of reality” underscores the social worker’s obligation to be sensitive to issues of cultural and ethnic diversity. The theory is applicable to many client populations—actually, to all people who have the capacity for cognition and reflection. The theory may have particular appeal to members of diverse populations who seek concrete, practi- cal approaches to problem solving, such as persons in lower socioeconomic groups, Latino clients, and African-American clients (Balter, 2012).
On the other hand, cognitive theory focuses on individuals and tends to limit its attention to the immediate rather than the macro environment. It does not encourage the social worker to look outside the client, except to consider environmental evidence for his or her beliefs about the world. In considering the “rationality” of a client’s thinking, practitioners may be as likely to support the acceptance of social conventions as to encourage social change activities when working with vulnerable or oppressed client groups (Payne, 2005). Sec- ond, though the theory encourages sensitivity to diversity, the social worker must always make difficult judgments about the “rationality” of a client’s think- ing. The less the social worker understands the client’s world, the more difficult will be the task of assessing the client’s rationality
