Cognitive Foundations of Clinical Psychology (Psychology Revivals)

Chris R. Brewin

• Publisher: Psychology Press
• Year: 2013
• ISBN:
  9781317932444
• Edition: 1
• Topic: Psychology
• Subtopic: Clinical Psychology
• Index: Psychology

Originally published in 1988, this was the first textbook to review and integrate the cognitive theories underlying the practice of modern clinical psychology. Written in a clear and readable way, it uses many clinical examples to relate the theories to what therapists actually do. It describes the strengths and weaknesses of the theories and develops a common framework drawn from research in social and cognitive psychology to explain the mechanisms of behavioural and cognitive therapy. Among the topics covered are the validity of self-reports; experimental investigations of nonconscious processes; cognitive theories of conditioning; the relation between cognition and emotional disorders such as anxiety and depression; self-esteem and the development of self-schema; self-efficacy; explanation and causal attribution; personal values and goals; self-regulation and the techniques of cognitive therapy. This textbook is designed for advanced undergraduate and postgraduate courses in clinical and abnormal psychology. Its practical focus will also make it of particular interest to practising clinical psychologists, psychiatrists and other mental health professionals.

1	Introduction: Cognition and Clinical Psychology

Since the early 1950s psychology has seen many significant developments. On the theoretical side, one of the most dramatic has been the decline of behaviourism and the rise of cognitive psychology, whereas on the practical side there has been an enormous expansion in the clinical applications of psychological knowledge. Much of the subject matter of clinical psychology, such as distressing thoughts and memories, delusions, and fixed ideas, is of course cognitive in nature, and in the last century psychoanalytic theories of psychopathology attempted to explain such phenomena. Breuer and Freud (1893), for example, attributed many hysterical symptoms to the presence of disturbing ideas or memories that had been repressed and made inaccessible to conscious awareness. Cognitive theories are not new, therefore, but it is only comparatively recently that they have come to play an important role in clinical psychology, backed up by the findings of systematic empirical research. In this chapter I want to outline briefly some of the ways in which cognitive theories, drawn from social psychology as well as from the experimental study of mental processes, can help to explain clinical phenomena and guide clinical practice.

The approach taken in this book is that psychological problems usually have multiple causes—personal, environmental, and sometimes constitutional. Often problems arise in the context of very real social difficulties, threats to well-being, and agonizing personal choices, either past or present. Sometimes situations that appear relatively non-threatening to the average person cause great distress or provoke an extreme reaction in a particular individual. Even in the case of severe environmental stressors, however, people seem to differ greatly in the nature and intensity of their reaction and in their ability to cope. This means that it is necessary to assess, not just what has happened in the eyes of a neutral observer, but how the person experiencing the event has understood it, what has been learned from it, and what the consequences are thought to be for the future. These subjective assessments are based on the integration of situational information with the person’s prior knowledge about the world. The judgements made in turn become incorporated into that knowledge, thereby affecting future judgements. The task of the various branches of cognitive psychology is to explain how knowledge is acquired, how it is internally represented and integrated with existing information, and what kinds of knowledge affect people’s feelings and behaviour. The task of the clinical psychologist is to apply this understanding to the enhancement of human potential and to the alleviation of suffering.

The theme of knowledge and its acquisition will be central to this book. In practice, the knowledge people require to evaluate stressful situations properly and decide on the appropriate course of action is often missing, or forgotten. Simply telling people relevant facts about the frequency of the problem or its most likely outcome may be extremely helpful to them. Even if relevant knowledge is available, the inferences that people are called upon to make about themselves and their circumstances are often complex and difficult, and human judgement is known in many cases to be all too fallible. For example, parents trying to explain why their child is truanting may have to integrate a huge amount of information about school circumstances, the behaviour of peers, current sources of stress, their own attitudes towards school and disciplinary styles, and so on. There is now a great deal of evidence that even in simple situations people’s ability to recognize the interdependence of events, identify causes, estimate the degree of control they have, and draw valid conclusions from a set of data, are quite limited and prone to be influenced by a variety of factors (e.g., Nisbett & Ross, 1980). It is known that people are strongly affected by prior expectations, that they are subject to various errors and biases, and that they tend to rely on simple rules or heuristics when faced with large quantities of information. Under these circumstances erroneous and premature judgements, made either by the patient or by the clinician, are likely to flourish, sometimes with the most unfortunate consequences.

It is equally evident that people are not always consciously aware of the knowledge they possess, and that their behaviour may be influenced by events that occur out of awareness (see Chapter 2). We shall therefore be examining the issue of unconscious knowledge as well as considering the sort of conscious judgements people make, how accurate they are, their consequences, and how they can be altered. But before going any further it is necessary to give some idea of the range of problems and situations to which today’s clinical psychologist is expected to contribute.

Contemporary Clinical Psychology

In the early days of behaviour therapy the main clinical focus was on anxiety neuroses, and in particular phobic and obsessional disorders. In terms of the then current (behaviourist) learning theory, disorders such as insect or height phobias were conceptualized as conditioned fear responses that had been acquired accidentally and that were elicited by contact with the conditioned stimulus (see Chapter 3 for a fuller account of conditioning theories). A variety of techniques, such as extinction and counterconditioning, were available for overcoming such examples of learned avoidance, and aversion therapy was also used to combat learned approach behaviours such as alcohol addiction and transvestism (Wolpe, 1973). This conditioning model, which was to lead to many innovative treatment strategies and to prove very influential in clinical psychology, was characterized by a concern with maladaptive habits and behaviours rather than with thoughts and feelings. It was based on principles derived from the study of animal learning and took little account of the person’s wider social and interpersonal context. It was also mechanistic in the sense that people’s behaviour was considered to be primarily shaped by environmental events, and that therapeutic improvement was expected to follow exposure to a different sequence of events.

Behaviour therapy began, then, with a fairly simple conception of a limited set of disorders. These represent only a small proportion of the workload of clinical psychologists, who are now involved in such diverse activities as marital and family therapy, the management of chronic pain, preparation for surgery, skills training for the mentally handicapped, the treatment of depression in the elderly, the assessment and rehabilitation of brain-injured patients, the management of alcoholism and drug addiction, and the counselling of the terminally ill and bereaved. The original focus on disturbed behaviour has given way to a concern with many aspects of human functioning, such as people’s emotional state, their thoughts, their memory and concentration, their ability to cope with difficult situations, their interpersonal problems, their sense of wellbeing or self-esteem, and their physiological health status. It is now recognized that assessment must include many or all of these areas of functioning, and that problems in different areas may require different kinds of intervention. Nor do psychologists confine their efforts to altering conditioned responses, but attempt to help people deal with the direct, unconditioned responses to major life stresses, such as going into hospital for a major operation or coming to terms with the loss of a loved one.

Cognitive theories are relevant to many of these aspects of the contemporary psychologist’s role. In this book it will not be possible to cover all aspects, and I therefore intend to concentrate on a limited set of phenomena that are widely encountered. A major focus will be on the nature, origin, and modification of emotional states, particularly anxiety and depression. These are important, not just in a psychiatric context, but anywhere that people are coping with major stresses. Another topic will be self-esteem and how it is maintained. Although particularly associated with depressive disorders, low self-esteem is common and there is evidence that people’s statements and actions are greatly influenced by attempts to protect and enhance their self-esteem. Motivational processes also receive a great deal of attention, as the issue of how much effort people are prepared to expend in therapy or in dealing with their problems is of concern in any area of clinical psychology. The fourth topic includes various social processes, in particular interpersonal emotions, cooperation and helping, that are relevant to understanding family and client–professional relationships. However far clinical psychological services develop, these four topics are certain to remain of central importance, whether the client groups are old or young and whatever the nature of their difficulties.

Cognitive Approaches in Psychology

The main distinguishing feature of a cognitive approach to psychological investigation lies in the emphasis given to mental processes that intervene between an environmental event and the reaction of a person or animal. Once simple reflex arcs are excluded, all events are thought to be mentally evaluated in various ways and compared to prior experiences stored in memory before being acted on. Thus, as noted by Eysenck (1984, p. 1), “virtually all those interested in perception, learning, memory, language, concept formation, problem solving, or thinking call themselves cognitive psychologists, despite the great diversity of experimental and theoretical approaches to be found in these various areas.” Experimental cognitive psychology is largely concerned with explaining how people perceive, attend to, classify, store, and remember information, and how they then use this information to make decisions. Typically the aim has been to develop general models of these processes, and little account has been taken of individual differences or motivational variables. Because the processes of interest are usually unavailable to introspection, inferences about their nature are often derived from computer simulations or from measures of human performance on experimental tasks. “Social cognition” refers to the relatively recent extension of this approach to the study of how social stimuli, such as information about oneself and other people, are registered and processed.

The idea that there are mental processes that intervene between stimulus and response is historically associated with the Gestalt school of psychology. Their theories were not only influential in explaining how objects in the physical world are perceived, but were soon extended to the perception of social objects and hence influenced the course of social psychology as well as the study of perception and thinking. Throughout the period when behaviourism was in the ascendant, social psychologists such as Lewin, Heider, and Festinger continued to emphasize the importance of conscious perceptions and evaluations in determining human behaviour. These theories invoked such mentalist concepts as expectancy, level of aspiration, balance, consistency, causal attribution, and cognitive dissonance, which did not correspond to directly observable behaviour but rather to hypothetical processes designed to account for behaviour. Unlike the theories stemming from experimental cognitive psychology, they were very much concerned with motivational processes, individual differences, and with the specific content of the information available to the person. Many current theories in clinical psychology, such as social learning theory (Bandura, 1977a) and learned helplessness theory (Abramson, Seligman, & Teasdale, 1978; Seligman, 1975), have their roots in this work.

Clinical psychology can therefore draw on both experimental cognitive psychology, with its focus on such processes as memory and attention, and cognitive social psychology, whose emphasis is more on conscious attitudes, expectancies, and beliefs. In addition clinicians themselves have come up with influential cognitive theories to account for the wide individual differences they meet in their work. For example, Kelly (1955) proposed that people have unique systems of personal constructs with which they categorize the objects in their world, interpret the events that happen to them, and predict the future. One of the main purposes of therapy, he suggested, is to help people free themselves from the restrictions imposed by their own construct systems. Ellis (1962) and Beck (1967) have also argued that dysfunctional emotions such as anxiety and depression follow from people’s perceptions and evaluations of the events in their lives rather than from the events themselves. Ellis’ Rational–Emotive Therapy and Beck’s Cognitive Therapy are both designed to alter these perceptions by a number of techniques, including challenging faulty underlying assumptions such as “I cannot live without this person” or “Nobody will ever speak to me again if I make a fool of myself”.

This brief overview is intended simply to give the reader some idea of the diversity of cognitive approaches relevant to clinical psychology. In the following chapters the various theories will receive much more detailed treatment and the evidence for and against them will be discussed. The important point to bear in mind is that, although all cognitive theories emphasize the importance of intervening mental processes, there is no one “cognitive approach”. Theories may deal with processes such as selective attention, or with structures such as “schemata” or “associative networks” that describe the organization of material in memory. They may be concerned with specific kinds of content, such as ideas, images, expectations, and attitudes, and this content may be accessible or inaccessible to consciousness. They may assert different kinds of causal relation between mental processes, emotions, and behaviour. This diversity means that the potential contribution of cognitive theories is considerable. In the rest of the chapter I illustrate this by discussing some major aspects of the onset a course of illness.

Cognitions as Precipitating Factors

The major factor associated with the onset of a wide range of physical and psychiatric disorders is life stress (e.g., Brown & Harris, 1978; Dohrenwend & Dohrenwend, 1974; Totman, 1979). Stress is thought, for example, to cause or exacerbate acne, anxiety, asthma, amenorrhea, arthritis, cancer, the common cold, coronary heart disease, diabetes, depression, duodenal ulcer, epilepsy, glaucoma, hypertension, insomnia, low back pain, leukaemia, migraine, neurodermatitis, premenstrual tension, post-operative infection, schizophrenia, stroke, tension headache, and ulcerative colitis. In spite of these numerous findings, simply counting the number of events, commonly regarded as stressful, that a person has experienced does not allow one to predict whether he or she will become ill with any great accuracy. Even responses to very serious stressors such as earthquakes or being interned in a concentration camp show enormous individual variation. Many authors have concluded that this is because the stressfulness of events depends, at least in part, on how they are evaluated or appraised by the individual (e.g., Lazarus, 1966).

Considerable research effort has therefore gone into describing the characteristics of stressful situations, and animal studies have consistently identified a number of factors leading to behavioural disturbances and abnormal physiological activity. Among the most common are threat of pain or other punishment, the frustration of goal-directed behaviour, conflict between equally attractive or equally unattractive goals, approach-avoidance conflict, helplessness, and loss of or separation from other animals. Although these characteristics can be defined as properties of a situation, they can also be treated as psychological states that are aroused in individuals to varying degrees. Research presented in Chapters 3 and 4 indicates that the response of animals and human beings to these situations often depends on the integration of a wide range of relevant information. For example, physiological responses to stimuli signalling shock vary according to whether an escape or avoidance response has previously been learned or is believed (erroneously) to be available (Miller, 1979). Such findings imply a need for some account of how different kinds of information are registered, stored, and integrated.

Outside the laboratory, too, most examples of human stress can be categorized as involving threat, conflict, loss, and so on. However, some of the events one person would find threatening, such as being offered promotion at work, others would find challenging. People also differ greatly in their response to loss and conflict. The enormous variety of goals that people can aspire to means that apparent frustration or conflict in one area may be relatively unimportant because of the presence of substitute goals, a topic that is covered more fully in Chapters 5 and 8. So, although certain situations may have profound physiological and behavioural consequences for both people and animals, those situations cannot be defined without considering the state of the organism as well as the state of the environment. According to the cognitive theorist, this internal state represents the outcome of various forms of appraisal and evaluation.

These points are illustrated in detailed research by Brown, Bifulco, and Harris (1987) on the kind of life events that tend to precede depression in female community residents. They point out that whereas on average four-fifths of depressed women have experienced a major stressor, only about one in five women experiencing such a stressor go on to become depressed. This association can be strengthened by considering only severe events that correspond either to ongoing difficulties (D-events), to particular areas of strong commitment (C-events), or to areas where role conflict exists (R-events). The significance of D-events is presumed to lie in the high levels of helplessness that accompany them, while C-events and R-events can be readily understood in terms of goal frustration and conflict. Brown et al. give, as an example of a C-event, a woman with a strong commitment to her role as a mother experiencing her son being put on probation for violent behaviour. The authors conclude (p.41): “The role of matching difficulties and commitments indicates the importance of the loss of something upon which one has heavily staked a part of oneself… The findings of course underline the importance of social environment and cognitive factors in the aetiology of depression”.

Cognitions as Vulnerability Factors

The wide variability in people’s response to stressful life events has also led to the suggestion that events only have severe consequences for individuals who are in some way permanently vulnerable. These diathesis–stress models, as they are sometimes known, include as potential vulnerability factors the experience of p...