Trial-Based Cognitive Therapy

Distinctive features

Irismar Reis de Oliveira

• Publisher: Routledge
• Year: 2016
• eBook ISBN: 9781317532644
• Topic: Psychologie
• Subtopic: Psychopathologie

Trial-Based Cognitive Therapy (TBCT) is a new model of cognitive behaviour therapy (CBT) that organizes standard cognitive and behavioural techniques in a step-by-step fashion, making CBT more easily mastered by the new therapist, more easily understood by the patients, and simpler to be implemented, whilst still maintaining flexibility and CBT's recognized effectiveness.

Dividing thirty key features into two parts: 'Theory and Practice', this concise book explores the principles of TBCT, explains the techniques developed throughout TBCT therapy to change dysfunctional cognitions, and provides a clear guide to the distinctive characteristics of TBCT.

Trial-Based Cognitive Therapy will be of interest to psychiatrists, psychologists, social workers, therapists, counsellors and other professionals working in the field of mental health, plus those wanting to learn CBT.

Trial-Based Cognitive Therapy is part of the Distinctive Features series, which asks leading practitioners and theorists of the main CBT therapies to highlight the main features of their particular developing approach. The series as a whole will be essential reading for psychotherapists, counsellors and psychologists of all orientations.

Part 1 THE DISTINCTIVE THEORETICAL FEATURES OF TBCT

DOI: 10.4324/9781315725000-1

1 Historical development and underpinnings of Trial-Based Cognitive Therapy (TBCT)

DOI: 10.4324/9781315725000-2

TBCT is a new model that, although still inherently Beckian, distinctively organizes known and standard cognitive and behavioral techniques into a step-by-step fashion in order to make cognitive therapy more easily mastered by the new therapist—more easily understood by patients, and simpler to be implemented—while still maintaining flexibility and CBT’s recognized effectiveness and transdiagnostic feature (de Oliveira, 2015).

TBCT development started with the publication of the Sentence Reversion-Based Thought Record (SRBTR; de Oliveira, 2007), which was a modified 5-column thought record designed to deal with “yes, but …” dysfunctional thoughts. During the elaboration of SRBTR, I used the downward arrow technique (Burns, 1980) to uncover the dysfunctional negative CBs, introduced sentence reversal (Freeman and DeWolf, 1992) to bring new positive meanings to the reversed sentences, and added the upward arrow technique (Leahy, 2003) to activate healthier positive CBs. Thus, by repeatedly using the SRBTR in session and as homework, my intention was to help the patient deactivate dysfunctional modes—a mode being defined by Beck (1996) as an interrelated sets of schemas—modifying them in structure and content, and finally, neutralizing them by the incorporation of a more credible explanation and by the activation of more adaptive modes. Theoretically, SRBTR was explicated taking the perspective of Teasdale’s Interacting Cognitive Subsystems (ICS; Teasdale, 1996; Teasdale and Barnard, 1993). The main goal of the treatment, according to the ICS view, was to substitute the synthesis of the depressogenic schematic models that maintained depression with the synthesis of alternative, non-depressogenic models, something possible only if one succeeded in making changes at the level of higher-order meanings. According to Teasdale (1996, page 36), creating small changes like “The man said ‘GO ON’” vs. “The man said ‘NO GO’” (and thus changing a small part of a total pattern of the implicational code) might be sufficient to fundamentally change the high-level meaning represented. Also, Teasdale (1996) asserted that the effect of changing a thought and its related specific meaning could, by changing a discrete corresponding section of an affect-eliciting, implicational code pattern, be sufficient to change the emotional response.

However, although SRBTR seemed to be useful in helping patients to restructure their CBs, a difficulty resided within the approach. The therapist would encourage the patient to immediately confront the CBs with evidence supporting them instead of evidence against them which was often invalidating for the patients, unless a solid alliance was established. With this problem in mind, and after much reflection, the solution came to me accidentally, as an inspiration when I decided to use the courtroom metaphor after seeing the novel The Trial, by Franz Kafka (1925/1998)—which I had read many years before—in a bookstore (See Chapter 2). It was not the first time the courtroom metaphor was used in CBT (Freeman and DeWolf, 1992; Cromarty and Marks, 1995; Leahy, 2003). The idea was simply conceptualizing the CB as a self-accusation, and adding two columns to the thought record, corresponding to the evidence confirming the CB (prosecutor), and the evidence not supporting it (defense attorney). Otherwise, all the other columns received a courtroom connotation, but were kept as originally designed, preserving the downward arrow approach (Burns, 1980), the sentence reversal procedure (Freeman and DeWolf, 1992), and the upward arrow technique (Leahy, 2003). The new, now-derived, thought record was named trial-based thought record (TBTR; de Oliveira, 2008).

Preliminary results of studies supported the TBTR use in different psychiatric disorders (de Oliveira, 2008; de Oliveira, Duran, and Velasquez, 2012c; de Oliveira, Hemmany, Powell, Bonfim, Duran, Novais, et al., 2012a). Besides demonstrating its efficacy in social anxiety disorder (de Oliveira, Powell, Caldas, Seixas, Almeida, Bomfim, et al. 2012b; Powell, de Oliveira, Seixas, Almeida, Grangeon, Caldas et al. 2013), the TBTR was shown to decrease the credibility given by patients to dysfunctional negative CBs and the intensity of corresponding emotions (de Oliveira, 2008; de Oliveira et al. 2012a, 2012b). The above-mentioned studies reached the conclusion that TBTR might help patients reduce attachment to negative CBs and the intensity of corresponding emotions, irrespective of the diagnosis.

Table 1.1 shows other techniques that were progressively added to the TBTR, resulting in a new psychotherapy approach called Trial-Based Cognitive Therapy (TBCT). Such techniques were modifications of standard CBT techniques and other approaches, making TBCT an example of assimilative psychotherapy integration (Messer, 1992; de Oliveira, 2013). In this kind of integration, various techniques from different theoretical origins are incorporated within the context of understanding provided by the home theoretical approach (Stricker, 2010). Thus, since its origin, TBCT relied on Beckian CBT as the organizing theory and added technical interventions drawn from several other approaches. Among them were Gestalt therapy, compassion-focused therapy, metacognitive therapy, mindfulness, and Mitchell's (1988) two-person relational model. Furthermore, by adding literature, TBCT relied on the work of Franz Kafka, The Trial (1925/1998), and its most important techniques incorporated the courtroom metaphor, by which the patient could express multiple internal characters (e.g., prosecutor, defense attorney, witnesses, jurors, etc.) to challenge her CBs conceptualized as self-accusations (de Oliveira, 2011). As TBCT was designed as a 3-level, 3-phase, structured step-by-step approach (See Chapter 3), and its conceptualization involved a cyclic interactional mechanism in which each component in each level influenced the other, this approach has shown to be flexible enough to allow the therapist to adapt the treatment to the individual's needs and characteristics.

The case conceptualization diagram (CCD), aiming to connect all the TBCT techniques and to organize their use during therapy, was the last TBCT tool developed, marking the beginning of TBCT as an individualized approach. This idea and the name ‘Trial-Based Cognitive Therapy’ was the result of a conversation between Robert Friedberg (PhD, Professor of Cognitive Therapy for Children and Adolescents at Palo Alto University) and myself, during the World Congress of Behavior and Cognitive Therapies (WCBCT), held in Boston, MA, from June 2–5, 2010.

Table 1.1 TBCT techniques and its diagrams. Column 2 details in which sessions they are usually used. Column 3 indicates the chapters in which the techniques are discussed.

Techniques and diagrams	Sessions in which they may be used	Chapters in which they are discussed
TBCT Case Conceptualization Diagram	All sessions	3, 5, 16, 22 and 25
Cognitive Distortions Questionnaire (CD-Quest)	All from session 2 on	4, 17 and 18
Intrapersonal Thought Record (Intra-TR)	Any from session 2 or 3 as needed	19
Interpersonal Thought Record (Inter-TR)	Any from session 2 or 3 as needed	20
Trial-Based Participation Assessment (TBPA)	Any session (as needed) for guilt/shame	21
Color-Coded Symptoms Hierarchy (CCSH)	Any from session 3 or 4 as needed	6 and 23
Consensual Role-Play (CRP)	Any from session 3 or 4 as needed	7 and 24
Trial-Based Thought Record (TBTR or Trial I)	Usually from session 5 on	9, 11, 26, 27 and 28
Trial-Based Metacognitive Awareness (TBMA or Trial II)	Usually from session 7 on	12 and 29
Relaxation with the Sail Boat Metaphor	Usually from session 7 on	30

2 Core beliefs about the self, conceptualized as self-accusations: contribution from literature to Trial-Based Cognitive Therapy (TBCT)

DOI: 10.4324/9781315725000-3

When I first designed the TBTR, it was my assumption that Franz Kafka in his novel, The Trial (Kafka, 1925/1998), aimed to propose a universal principle of self-accusation by human beings. If this interpretation happens to be consistent, self-accusations could occur as the schemas and core beliefs about the self, described by cognitive therapists. Consequently, it would be possible to establish an investigation intended to uncover such self-accusations, and summon the characters in the inner tribunal to help the person judge herself more rationally and realistically (de Oliveira, 2011).

Although psychological interpretations of Kafka’s writings have been found in various psychoanalytical s...

Table of contents

• Cover Page
• Half Title Page
• Title Page
• Copyright Page
• Table of Contents
• Figures
• Tables
• Acknowledgments
• Abbreviations
• Introduction
• Part 1 The Distinctive Theoretical Features of Tbct
• 1 Historical development and underpinnings of Trial-Based Cognitive Therapy (TBCT)
• 2 Core beliefs about the self, conceptualized as self-accusations: contribution from literature to Trial-Based Cognitive Therapy (TBCT)
• 3 Trial-Based Cognitive Therapy (TBCT): a 3-level, 3-phase case conceptualization approach
• 4 Assessing cognitions: the cognitive distortions questionnaire (CD-Quest)
• 5 The modulatory role of underlying assumptions (UAs)
• 6 Separating discomfort from distress: the color-coded symptom hierarchy (CCSH)
• 7 Resolving ambivalence
• 8 A focus on experiential techniques for restructuring cognitions
• 9 Core beliefs about the self, conceptualized as self-accusations
• 10 Distinguishing the inner characters: taking distance
• 11 The “preparation for the appeal” metaphor: building new positive and functional core beliefs
• 12 Metacognitive awareness
• 13 TBCT and social anxiety disorder
• 14 TBCT and post-traumatic stress disorder
• 15 TBCT as a preventive approach for adolescents in schools
• Part 2 The Distinctive Practical Features of Tbct
• 16 Explaining the cognitive model. Case formulation: level 1
• 17 Assessing dysfunctional cognitions
• 18 Introducing the CD-Quest
• 19 Using the intrapersonal thought record (Intra-TR)
• 20 Using the interpersonal thought record (Inter-TR)
• 21 Using the trial-based participation assessment (TBPA) to resolve guilt
• 22 Case conceptualization diagram, level 2
• 23 Using the color-coded symptom hierarchy (CCSH): discomfort vs. distress
• 24 Resolving ambivalence and making decisions: the consensual role-play (CRP)
• 25 Case conceptualization diagram: level 3
• 26 Using Trial I to restructure dysfunctional CBs
• 27 Using Trial I to change multiple core beliefs
• 28 Using Trial I in group settings
• 29 Using Trial II to promote metacognitive awareness
• 30 Relaxation and the sailboat metaphor
• References
• Index