Developmental Cognitive Behavioral Therapy with Adults

Janet M. Zarb

• Publisher: Routledge
• Year: 2013
• eBook ISBN: 9781135913724
• Topic: Psychologie
• Subtopic: Psychologie clinique

Developmental Cognitive Behavioral Therapy with Adults outlines a new cognitive approach that combines existing CBT theory and strategies with a lifespan developmental psychopathology perspective.

The major focus is on the relationship between mastery of normative psycho-social developmental tasks and mental health. Primary targets for therapy are maladaptive developmental pathways that have significantly disrupted the client's ability to cope with normal adult tasks and challenges.

The book builds on standard cognitive therapy models and techniques, while providing further assessment and therapy strategies to address patterns interfering with resolution of normative adult tasks and roles. It introduces several new developmental assessment and therapy strategies, designed to address client difficulties with normal adult developmental tasks and to identify longstanding maladaptive pathways maintaining these difficulties.

The book offers a variety of psycho-social developmental task difficulties in occupational, social, and family functioning. The clinical examples provide a deeper understanding of pathways to competence, as well as pathways to deviance, and the contrast between normal and atypical processes as they emerge at different developmental periods.

1

Introducing the Developmental Cognitive Behavioral Therapy Approach

The aim of this book is to introduce a new psychotherapy approach that combines conventional cognitive therapy with a lifespan developmental psychopathology perspective. The major focus will be on treatment of adult role difficulties contributing to mental health problems. This approach examines the relationship between depression, anxiety, personality disorders, and other psychological problems and the client’s difficulties in performing expected adult roles and tasks. It adopts a developmental psychopathology framework that considers behavioral and emotional problems in relation to normative sequences and achievements for particular ages and stages across the life cycle. This new approach will be referred to as Developmental Cognitive Behavorial Therapy, or Developmental CBT.

The initial phase of Developmental CBT adopts the most studied and commonly used CBT model developed by Aaron Beck and his colleagues and expanded by other therapists over the past forty years (e.g., Beck, 1976; Beck & Emery, 1985; Beck & Freeman, 1990; Beck et al., 1979; Beck, J., 1995; Meichenbaum, 1994; Padesky, 1994; Young, Beck, & Weinberger, 1993). This model is also frequently referred to as cognitive therapy (CT). The primary difference between the new Developmental CBT approach espoused in this book and traditional CBT approaches is the addition of a developmental phase of assessment and treatment that focuses on the client’s inadequate resolution of normative psychosocial developmental tasks and transitions of earlier life stages. This approach evolved from a common observation by the author and other clinicians that a substantial proportion of people seeking therapy are experiencing problems with adult life tasks and roles, such as leaving the parental home, coping with social or family relationships, or maintaining effective occupational status (Ruble & Seedman, 1996). Many psychotherapy clients are stuck at life transitions and have failed to resolve critical life-stage tasks in the past in occupational, interpersonal, partner, or family functioning areas.

In an attempt to address the client presenting problems and comorbid Axis I and II disorders, therapists may lose sight of the larger picture, namely the client’s failure to resolve normative life tasks that may be maintaining the psychological disorders. For example, clients presenting with depression secondary to unemployment may have failed to develop sufficient self discipline in the early years for adequate job performance as adults. Similarly, they may have failed to attain educational prerequisites for a desired occupation or failed to develop sufficient independence from family of origin to establish a separate residence and viable career path.

The Evolution of the Developmental CBT Approach

The integrated Developmental CBT approach outlined in this book evolved from years of clinical experience with both adolescent and adult clients manifesting developmental task difficulties at different age periods across the life span. It became clear that in addition to Axis I and II disorders and debilitating environmental stressors, many clients were also unable to perform what would be considered to be routine psychosocial tasks of various life stages, such as forming and maintaining satisfying interpersonal relationships with friends and colleagues or with intimate partners, leaving the parents’ home and establishing an independent health-enhancing routine and career, or providing effective parenting. These developmental task difficulties often affect other areas of functioning as well, so that social, family, and work experiences may all be diminished in some cases. This fundamental observation suggested a need for developing new strategies specifically designed to address adult developmental task and role blocks. In this book, psychosocial Developmental Task Difficulty will be used to denote diminished psychological ability to negotiate normative life tasks, with roots dating back several years. These difficulties may also be referred to as developmental task blocks.

Haracteristic Role Difficulties of Early, Middle, and Late Adulthood

Particular role difficulties are characteristic of different life stages. During the early-adulthood years, clients tend to present with difficulties forming intimate partner relationships, difficulties initiating viable occupational paths, or difficulties leaving parents and establishing an independent adult life structure. There may be reluctance to make major commitments in areas of intimate partner relationships or occupational paths. Later on, during middle adulthood, clients may present with problems maintaining satisfying partner relationships or steady employment or problems functioning as effective parents. Some clients are unable to negotiate crucial life-course transitions such as terminating a destructive partner relationship or restructuring an unsuccessful initial career choice in order to pursue an alternative career with potential for sufficient economic remuneration or career satisfaction. Worries about being surpassed by younger colleagues may also surface at this stage. Mature adult clients may present with problems coming to terms with unfulfilled youthful occupational or relationship aspirations, so that they are unable to restructure goals and move on. A common complaint is that of being too old to rectify unfulfilled goals. Failure to resolve normative challenges not only increases a client’s vulnerability to depression, anger, and anxiety disorders, but also decreases the person’s ability to cope with unexpected stressful and tragic life events.

The Developmental CBT approach presented in this book combines standard cognitive-behavioral therapy techniques with new developmental assessment and therapy strategies and techniques that have been created and field tested by the author over several years for clients with a variety of developmental task difficulties. These new strategies, to be introduced in the next two chapters, have been designed to help clients identify psychosocial developmental blocks and to master steps necessary to resolve normative life-course transitions and roles to the extent that daily functioning and mental health begins to improve. The most challenging clients are those with coexisting personality disorders that render them highly resistant to altering their self-defeating developmental patterns. Often these dysfunctional patterns have helped them to cope with stressful situations and developmental challenges during childhood, adolescence, or earlier adult periods, but are no longer working for them and are delaying normal transitions.

Life Span Developmental Perspectives on Normal and Abnormal Psychosocial Development

A major concept of life span developmental perspectives is the notion of a life cycle composed of loosely denned developmental stages or phases. Life is a series of growth stages that the individual and family must successfully negotiate to avoid stagnation and chronic crisis. The concept of life stages provides a useful framework for identifying normative developmental tasks related to biological forces and to age-related social and cultural expectations that lead to changing roles. An underlying assumption is that an individual must master certain tasks at each developmental stage before successfully moving on to the next stage. Those who meet developmental challenges at a particular stage have developed skills that make them better equipped to meet successive new developmental challenges of later stages. Mastery of normative developmental tasks also increases the person’s likelihood of successfully coping with nonnormative events or crises that may occur at any time in one’s external environment, such as the death of a family member.

Social scientists in past decades have generally supported the notion of age-linked developmental periods for the preadult years. Children are viewed as going through an underlying sequence of common developmental periods of infancy, early childhood, middle childhood, pubescence, and adolescence, and psychologists have identified critical developmental tasks that must be mastered for a successful transition to adulthood (e.g., Conger, 1977). In recent decades developmental theorists have raised the possibility of identifying and documenting sequences of developmental periods and tasks of adult years, similar to those of childhood and adolescence. In spite of the common underlying sequence of developmental tasks, the diversity of different biological, psychological, and social conditions for each individual results in the uniqueness of each child. Child and adult developmental task literature influencing new developmental assessment instruments to be introduced in Chapter 2 includes the following: Bowlby, 1988; Carter & McGoldrick, 1989; Cohler & Boxer, 1991; Conger, 1977; Erikson, 1982; Featherman et al., 1994; Guidano, 1987; Havinghurst, 1972; Levinson, 1978, 1996; Okun, 1984; Vandenbos, 1998.

A life span developmental psychology perspective adopts the notion of normative developmental challenges or crises frequently occurring at transition periods between life stages, accompanied by increased vulnerability to stress. A temporary developmental crisis is considered within normal limits, and for most people it provides an opportunity for positive growth as the person resolves the crisis and moves on. However, transitional challenges may prove to be ongoing unresolved crises, spanning months or even years, depending on the individual’s coping style and external stress factors. Often basic skills for resolution of the normal developmental challenges are poorly developed.

A useful distinction has been made between developmental and nondevelopmental crises. Developmental challenges or crises are shaped by biological forces and age-related social and cultural expectations. They occur in response to the individual’s attempts to cope with predictable, age-related challenges faced by most people, usually in relation to family, peer, and educational or occupational roles. Developmental challenges and crises emanate from tasks within the context of normal development and are frequently accompanied by symptoms of psychological distress. Mental health professionals may differ in their views of what constitutes a normal developmental challenge. For example, in light of the relatively high frequency of job loss and divorce in the present day, some may view these events as common developmental crises.

Nondevelopmental challenges or crises, such as accidents, physical problems, or abusive situations, occur in response to atypical, unpredictable challenges or external events that have no direct connection to age-linked periods. They are sometimes referred to as situational crises. Developmental and nondevelopmental crises may occur simultaneously, and sometimes a nondevelopmental crisis precipitates a developmental crisis. It is expected that situational crises will have the greatest negative and long-term impact when they interfere with resolution of major adult tasks and roles such as completing one’s education, entering the work force, or forming a stable long-term partner relationship (Cohler, 1991).

A transitional crisis is a novel situation with new role demands. Therapy clients frequently experience difficulty meeting task demands because habitual problem-solving strategies and coping skills no longer work. From a cognitive-therapy perspective, the client may be having difficulty mastering the prerequisite cognitive interpretation and behavioral coping skills for successful task resolution and is therefore unable to come to a decision as to what to do. An important consideration is the degree to which the client had been able to successfully resolve similar normative transitions and novel role demands in the past.

Difficulties with normative developmental tasks and roles increase a person’s vulnerability to external stressors and comorbid Axis I and II disorders. Mental health is seen in the context of the client’s whole life cycle and the ability to successfully perform culturally expected roles, to resolve expected transitional crises, and to cope with disruptive adverse external life events and get back to adaptive daily functioning. Healthy psychological development assumes client achievement of normative sequences and milestones for particular ages and stages (Cohler & Boxer, 1991).

Although authors vary somewhat in their designation of primary developmental tasks that children and adolescents must negotiate in order to develop in a healthy manner, most concur with the following five developmental tasks summarized by Young (1990): (1) autonomy, or the sense that one can function independently in the world; (2) connectedness, or the sense that one is connected to other people in a stable, enduring, trusting manner; (3) worthiness, or the sense that one is loveable, competent, acceptable, and desirable to others; (4) reasonable expectations, or the capacity to set realistic, achievable standards for oneself and others; and (5) reasonable limits, or the capacity to discipline oneself and to appropriately take the needs of others into account. Similarly, Levinson (1978) concludes on the basis of his adult life span research that psychological development in early adulthood may be considered healthy if the person has aspirations and establishes goals; forms satisfying relationships, makes commitments to persons and enterprises in family, work, and social spheres; strives with some enthusiasm and self-discipline toward attaining occupational goals; and develops competence in various adult social roles.

Mental health is also dependent on the individual’s own perception of himself or herself as functioning normally. There is general agreement among people within particular age and cultural cohorts on the proper timetable for specific role transitions, such as leaving school, marriage, birth of first child, and securing a first entry-level job. People tend to use this timetable as a yardstick for evaluating their own lives and their own progress. Therefore, transitions may have a negative impact when they are developmentally off-time, off-sequence, or delayed.

Concepts of Developmental Psychopathology: Psychopathology as Developmental Deviation

The term developmental psychopathology has been used to refer to a general approach to understanding relations between human development and its maladaptive deviations (Auchenbach, 1990; Cicchetti, 1990; Ciccetti & Cohen, 1995; Rutter & Stroufe, 2000). In recent decades, the emergence of developmental psychopathology has involved an integration of various disciplines. Normative changes that occur across the life cycle are taken into consideration, and behavioral and emotional problems are considered in terms of their relationship to normative sequences and achievements for particular ages and stages. A developmental psychopathology perspective does not prescribe particular theoretical explanations for psychological disorders but instead, provides a framework for organizing the study of psychopathology around milestones and sequences in physical, cognitive, social-emotional, and educational-vocational development. Consequently it is important to distinguish those developmental variations that are considered to be within normal limits from those that are more ominous, either because they disrupt development or because they reflect a pathological process that predicts a negative future prognosis for mental health.

If psychopathology is viewed as a distortion, disturbance, or degeneration of normal functioning, it follows that therapists who wish to understand pathology more fully must first understand the normal functioning against which psychopathology is compared (Cicchetti, 1984). To distinguish what is normal from what is potentially pathological at each stage, clinicians first need to be familiar with normative psychosocial developmental tasks for different adult periods. The academic basis of a developmental psychopathology perspective is longitudinal research on continuities and discontinuities of problems across developmental periods and identification of syndrome patterns requiring special help at each stage. Important contributions to the developmental psychopathology literature include studies of the relationship between early negative family, peer, and school experiences and subsequent adult task difficulties and mental health problems (e.g., Bagwell et al, 1998; Baldry & Farrington, 2000; Bedrosian & Bozicas, 1994; Deater-Deckard, 2001; Perris et al., 1994; Young, Klosko, & Weisharr, 2003). Developmental psychopathology focuses on specific skill deficits that function as mediators or links to areas of dysfunction. For example, mediators for inadequate peer relationships may be poorly developed social cognition skills or emotional regulation skills (Deater-Deckard, 2001). It is therefore up to therapists to devise ways to help clients address these mediators or skill deficits.

Investigations focusing on the negative impact of early dysfunctional parenting influences on adult psychopathology are particularly relevant to Developmental CBT (e.g., Bedrosian & Bozicas, 1994; Perris et al., 1994; Skinner & Wellborn, 1994; Young, 1990). For example, an underlying assumption of Skinner and Wellborn’s theory of coping across the life span is that all people have basic needs for relatedness to others, for competence, and for autonomy or self-determination. On the basis of this assumption, it is possible to derive dimensions of universal stress, namely, events that threaten or damage these three basic psychological needs. Three universal stressors posited are neglect, because it threatens relatedness, chaos, because it undermines competence, and coercion, because it impinges on autonomy. Coping involves a person’s endeavor to maintain, restore, replenish, and repair the fulfillment of basic psychological needs in the face of assaults on these needs. Clo...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright
• Contents
• Chapter 1. Introducing the Developmental Cognitive Behavioral Therapy Approach
• Chapter 2. Developmental Cognitive Behavioral Therapy Assessment Strategies
• Chapter 3. Developmental Cognitive Behavioral Therapy Intervention Strategies
• Chapter 4. Maladaptive Developmental Patterns Affecting Occupational Functioning
• Chapter 5. Maladaptive Developmental Patterns Affecting Social Relationships
• Chapter 6. Maladaptive Developmental Patterns Affecting Intimate Partner and Family Functioning
• References
• Index