The Mind in Therapy

Cognitive Science for Practice

Katherine D. Arbuthnott, Dennis W. Arbuthnott, Valerie A. Thompson

• Publisher: Routledge
• Year: 2014
• eBook ISBN: 9781317824237
• Topic: Psychology
• Subtopic: Clinical Psychology
• Index: Psychology

Human mental capacities and processes are the raw materials with which psychotherapists work. Thus what cognitive scientists have discovered in recent decades is potentially tremendous value for psychotherapeutic practice. But the new knowledge is not readily accessible to therapists, who find both language and methodology off-putting.

The Mind in Therapy bridges the gap. It offers a comprehensive overview of the relevant range of cognitive activities, ranging from complex mental operations such as problem solving, decision making, reasoning, and metacognition to basic functions such as attention, memory, and emotion. The authors integrate key new findings about the interaction between cognition and emotion, inhibition, and counterfactual thinking--processes that loom large in practice. Each chapter reviews an area of cognitive research, clearly explains the findings, and highlights their implications and applications in diverse models of therapy--cognitive, behavioral, psychodynamic, humanistic, and family. Each includes case vignettes that illustrate the ways in which the concepts are important and useful in practice.

All therapists rely on the human mind to effect the change they seek. The clearer understanding of human cognitive capacities, idiosyncrasies, and limitations--their own as well as clients'--that they will gain from this book will enhance the effectiveness of both beginning and experienced practitioners, whatever their orientation.

1
Introduction

Human mental capacities and processes are the raw materials with which psychotherapists work. Thus cognitive science research, which examines processes of thought, memory, and emotion, is potentially of tremendous value for psychotherapeutic practice (D’Zurillo & Nezu, 2001; Ingram & Kendall, 1986). As many clinicians have noted, knowledge about cognitive abilities, tendencies, and limitations could benefit both assessment and treatment by providing therapists with a clearer focus for intervention (e.g., Ingram & Kendall, 1986; Nasby & Kihlstrom, 1986; Winfrey & Goldfried, 1986). Furthermore, the cognitive processes of therapists themselves can lead to potential biases of interpretation that may influence their effectiveness, and it is important to understand them (Turk & Salovey, 1986). However, most recent syntheses of our rapidly expanding body of knowledge about cognition are not readily accessible to therapists, in either language or methodology, so the findings are not fully utilized by the psychotherapeutic community. The cognitive literature, describing, as it does, detailed experiments that don’t match their interests and training, tends to be difficult for most therapists to read. Conversely, most cognitive researchers are not familiar enough with the practice of psychotherapy to present their results to therapists in a way that clarifies their usefulness. The purpose of this book is to bridge the gap between empirical findings of cognitive science and psychotherapeutic practice. We review research focusing on a range from complex mental activities such as problem solving and decision making to basic functions such as attention and memory, and highlight the findings that are most relevant to therapeutic practice.

Research indicates that, although therapy is effective for mental health difficulties, clients’ outcome does not differ according to the orientation of their therapist (Chambliss & Ollendick, 2001; Elkind, 1994; S. D. Miller, Duncan, & Hubble, 1997; Saunders, 2004; Wampold, 2001). This is surprising, given the large theoretical and methodological differences between therapeutic orientations such as psychoanalysis, cognitive behavioral therapy, humanistic therapy, experiential therapy, and family therapy. The absence of clinically relevant differences across therapeutic orientation has led to a consideration of factors that are common to all modalities, such as the therapeutic relationship (S. D. Miller et al., 1997; Norcross, 2002; Wampold, 2001), and to integrative approaches to psychotherapy (e.g., Norcross, 1997; Norcross & Goldfried, 1992; Saltzman & Norcross, 1990; Stricker & Gold, 2003). However, one of the most fundamental commonalities in all therapeutic endeavors, and indeed in all human activity, is cognition. Thus, both therapists’ and clients’ cognitive processes are likely among the common factors that influence therapeutic outcome. As in the case of other common factors, a better grasp of their operation can greatly improve the use of cognitive resources for clients’ benefit.

The operation of cognitive processes imposes constraints and opens avenues for therapeutic change. The constraints include both operational limits such as attentional capacity (see chapter 7), and habitual limits such as confirmation bias in decision making and reasoning (see chapters 9 & 10). Avenues for change include precise assessment of client difficulties and limitations (Nasby & Kihlstrom, 1986), and interventions aimed at altering cognitive contents and processes (e.g., A. Wells, 2000; Winfrey & Goldfried, 1986). For centuries, philosophers have taken for granted that the world is mediated through our minds. We have no direct access to reality, and know the world only as it is filtered through cognitive processes such as perception and memory. Understanding how the “filter” works will simultaneously protect therapists from incorrect interpretations of the filtered reality (e.g., mistaking priming effects for importance in memory; see chapter 3) and provide opportunities to shift comprehension to benefit their clients. For example, realizing that our mood influences our cognitive style such that we think more creatively in good moods and more analytically in bad moods (chapter 13) can prevent us from interpreting a problem as unsolvable whichever mood we are in and suggests that we can use mood alteration as one means to influence problem solving.

It is sometimes argued that cognitive scientists’ formulations of mental processes such as attention, memory, and reasoning are too mechanistic and reductionistic to contribute much to the complex, interwoven realities that are the target of psychotherapy. We disagree. Knowledge of how these processes operate, and of the constraints imposed by their habitual use, can deepen our understanding of how psychotherapeutic techniques function to improve clients’ lives and of why some techniques don’t work for some clients. For example, the application of techniques such as reframing and restructuring of belief systems can only be improved by knowledge of how mental frames and structures operate in the first place. Approaches such as cognitive behavioral therapy include techniques to consider the content structures of memory (e.g., R. E. McMullin, 2000), but cognitive psychology can enable therapists to consider the processes by which these structures are formed and changed.

Of all the information available to us, some types influence our thoughts and actions to a much greater degree than others (e.g., see chapters 7, 9, & 10). Certain interpretation biases are used to simplify input, facilitating rapid thinking and decision making with a reasonable, but not perfect, degree of accuracy. Since many schools of psychotherapy promote self awareness for both therapist and client in order to minimize bias, it is particularly helpful for therapists to be aware of the cognitive processes underlying such biases. The chapters in this book outline what we know about such information use and biases in attention (chapter 7), memory (chapters 3–6), categorization (chapter 8), decision making and reasoning (chapters 9 & 10), and problem solving (chapter 2). Psychotherapy already makes use of these design features of the human mind, usually without awareness, and therefore not always to the best effect, and sometimes even to clients’ and therapists’ detriment. Explicit recognition will allow therapists to maximize their use of interpretation biases in the service of their clients’ goals.

During the past few decades, cognitive scientists have developed detailed models of mental processes, building from the components of perception and thought (e.g., attention, memory) to complex mental activities (e.g., problem solving, decision making). As it is precisely these mental processes that they target in their work, an up-to-date cognitive model is of enormous value to therapists. Each chapter in this book reviews an area of cognitive research, targeting findings that are particularly relevant to psychotherapeutic practice and theory, and highlighting therapeutic implications and applications. The book is directed widely to all therapeutic orientations, not only those employing cognitive behavioral techniques, because all therapies use the basic processes of the human mind to effect change. The aim of this book is to increase therapists’ understanding of their own and their clients’ mental processing, thereby increasing the effective therapeutic use of the capabilities and idiosyncrasies of human cognition.

Such an understanding is potentially of great benefit to both experienced and developing therapists. The former will explore new ways to conceptualize techniques that they have found effective or new tools to add to their therapeutic armamentarium. The latter will be given a framework of cognitive functions that can serve as a foundation for more applied knowledge. Regardless of their level of experience, some therapists will find that the ideas in these chapters do not greatly change their practice, whereas others will find that they substantively alter therapeutic encounters. All will find that knowledge of cognitive processes improves their comprehension of their clients’ interpretation of their world and the possibilities for change via the many noninvasive therapeutic techniques.

The book is intended to ground psychotherapy in science, but not in the way that manualized or empirically based treatment does (Chambliss & Ollendick, 2001; Henry, 1998; Silverman, 1996). The chapters have more in common with knowledge- or technology-transfer than with outcome-based therapy research. Knowledge transfer involves applying empirically supported findings and theories from basic science to a specific practical area or problem. That is the strategy of this book. Our approach is also consistent with the ideas of technical eclecticism as a form of psychotherapeutic integration (e.g., Beutler, Alomohamed, Moleiro, & Romanelli, 2002; A. A. Lazarus, 1992; Norcross & Newman, 1992). We describe selected findings and theories of cognitive science that are relevant to both the thinking of the therapist and that of the client, outline the implications of these findings and theories for therapeutic practice, and provide concrete examples of how a therapist might alter or strengthen her or his practice based on them. Therapy techniques based on these extensions of cognitive science have not often been empirically tested. However, we hope that the ideas in this book will both assist therapists immediately and prompt more applied research to test the speculative extensions.

Some caveats before we proceed: This book will not emphasize neuropsychology. Although knowledge of the anatomy and neural pathways underlying such processes as attentional control, language, and facial processing is useful for psychotherapists, other writers have provided excellent summaries (e.g., Cozolino, 2002). We contend that knowledge of what occurs in each of these anatomical locations, the metaphorical software, is likely to be of greater use to the theory and practice of individual change that is the goal of psychotherapy. As a rule, the book also will not compare the cognitive performance of special populations with that of normal populations, discussing instead human processes in general. Evidence suggests that individuals differ in the range of performance, but not in the way that cognitive performance is accomplished, so understanding the overall process is primary to assessing the minor variations evident across individuals and groups.

To maximize the usefulness of this information for psychotherapists, each chapter is structured in a similar manner. In each we begin with general definitions of key terms, and then explain why findings in the area are important for therapists. We follow with a more detailed presentation of the findings. To make the clinical implications as clear as possible, in most chapters we also include a hypothetical case illustration, which is used to demonstrate the extension of key cognitive points to a therapeutic context. These hypothetical cases are based on actual therapy cases but have been combined, reformatted, or both to highlight the relevant concepts and to protect the anonymity of our clients. The introduction to the case illustration for each chapter generally appears midway through the chapter, following the presentation of definitions and basic concepts. Continuations of the case then follow at various points throughout the chapter, to illustrate how cognitive information might be used to improve treatment. And finally, because each chapter contains a considerable amount of material, each ends with a brief summary of the key points addressed in the chapter, in order to facilitate learning.

The next eleven chapters (chapters 2–12) review both “higher mental processes” such as problem solving (chapter 2), categorization (chapter 8), reasoning and decision making (chapters 9–11), metacognition (chapter 12), and more basic processes such as attention (chapter 7) and memory (chapters 3–6). Higher processes are obviously key in psychotherapy, both for clients and for therapists. For example, therapists must assess their client’s issues and resources, whether or not they employ formal assessment, and this is essentially a process of categorization (chapter 8). Difficulties with processes such as problem solving or decision making often bring clients to psychotherapy, and therapists must engage in both of these processes in designing their treatment and choosing the techniques they will use with each client. The basic processes of attention and memory, however, set the stage for these larger-scale acts of thinking, in that we can only consider thoughts and feelings that have entered our attention or memory. These basic processes are thus central to psychotherapy (and all human functioning), and provide unique opportunities for therapeutic intervention, as discussed in each of these chapters.

The three chapters before the conclusion deviate somewhat from the mainstream cognitive literature. Chapter 13 describes the interplay between emotion and cognition. Emotion is also a mental process, and therefore theoretically falls within the domain of cognitive science. Although cognitive researchers have turned their attention to this important process only recently, findings about the ways in which thinking and feeling interact are vital to therapeutic work, and thus are reviewed in some detail. Chapter 14 discusses recent studies of inhibition by both cognitive and clinical researchers; it examines the conditions under which inhibition both harms and benefits mental health and functioning. Chapter 15 considers how cognitive theory is being used to test some of the basic principles and methods of psychodynamic therapy. These chapters do not contain case illustrations, but rather address therapeutic issues throughout.

The final chapter integrates and summarizes the main points. Although the challenges of studying an invisible phenomenon such as human cognition require researchers to look at mental components separately (Juola, 1986), we think holistically, with all processes operating simultaneously. Furthermore, psychotherapy also requires attention to entire persons, not just to various aspects of their thinking. Thus it is important that readers be left with an awareness of how these processes might interact over the course of therapy. The chapter discusses which cognitive processes are relevant at various points in therapy, from the initial session to termination, putting together the many pieces that have been laid out throughout the book. In sum, the book will enable therapists to understand cognitive processes and use their understanding to benefit their clients and enhance the effectiveness of their practice.

2
Problem Solving: The Structure of Psychotherapy

A person is confronted with a problem when he wants something and does not know immediately what series of actions he can perform to get it.

—Newell and Simon (1972, p. 72)

Much that happens in psychotherapy is a process of problem solving. Clients entering therapy develop, with the assistance of the therapist, a variety of change goals, including internal, external, and behavioral changes. Internal goals typically involve feeling differently or changing self-defeating thought patterns. External goals involve, for example, improving relationships, employment, or living conditions or specific behavior goals, such as changing addictive or abusive behaviors. Of course, individuals solve many such problems independently over the course of their lives, but problems that cannot be solved using a person’s usual repertoire of resources and strategies are the basis for psychotherapy. The client and psychotherapist engage in a collaborative process designed to solve the presenting or underlying problem. Thus, knowledge of processes that facilitate and hinder problem solving can be extremely useful for psychotherapists. Although we are not the first to make this assertion (e.g., Carkhuff, 1987; D’Zurilla & Nezu, 2001; Egan, 1994; Ingram & Kendall, 1986; Ivey & Ivey, 1999), previous authors discussed only a limited range of problem-solving research.

There are two qualitatively different approaches to solving problems, depending on the solver’s familiarity with the specific type of problem. If one has experience with a problem type (i.e., expertise), solutions can be formulated based on knowledge and experience. This describes much of the problem solving in therapy,¹ since psychotherapists have expertise in the types of problems that they treat. In unfamiliar or unique situations, solutions must either be created from scratch or adapted from prior experience, processes known as heuristic and analogical reasoning. Psychotherapists of many different schools and approaches attempt to transfer to their clients the expertise they have in general problem solving or the knowledge they have relevant to solving a particular kind of problem. However, because all clients and their life circumstances contain unique elements, therapists also help their clients to “custom build” solutions. Thus, some of the problem solving that occurs in psychotherapy falls into the domain of heuristic or analogical problem solving, as therapist and client collaborate to find new solutions to a client’s problems, or to extrapolate solutions from past successes.

Since Newell and Simon’s groundbreaking work in the 1970s, cognitive psychology has yielded much information about how people solve problems. Although early research focused on simple logic or physical problems, the field has expanded to include problem solving in a wide variety of domains, including medical diagnoses and decision making, textbook learning, sports problems, and many others (e.g., Adelson, 1981; Lesgold et al., 1988). These studies reveal a remarkable degree of consistency in their findings, regardless of whether the topic of study is college students learning to solve physics problems or medical residents learning to read x-rays. Thus, the findings can be readily generalized to personal problem solving, as practiced in psychotherapy.

Case Illustration:

A man in his early 40s was referred for therapy. He had recently been transferred from another city to assume a high level position in a midsized corporation. He had been divorced for four years and his 2 children (ages twelve and fourteen) remained with their moth...

Table of contents

• Cover
• Title
• Copyright
• Dedication
• Contents
• Acknowledgments
• 1 Introduction
• 2 Problem Solving: The Structure of Psychotherapy
• 3 Memory Retrieval Cues and Priming
• 4 Autobiographical Memory: The Stories and Scenes of Our Lives
• 5 Autobiographical Memory Errors
• 6 Prospective Memory and Psychotherapeutic Homework
• 7 Attention: The Eye of the Mental Hurricane
• 8 Category Judgment
• 9 Decision Making: Gathering and Evaluating Evidence
• 10 Reasoning: Evaluating Conclusions and Determining Cause
• 11 Counterfactual Thinking: If Only and What If
• 12 Metacognition: What You Know About How You Think
• 13 Emotion and Cognition: Mutual Influences
• 14 Catharsis or Containment: Inhibition and Health
• 15 Psychodynamic Principles as Cognitive Mechanisms
• 16 Prospect and Review: Cognition Throughout the Process of Therapy
• References
• Author Index
• Subject Index