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Crittenden - Attachment and Cognitive Psychotherapy

Crittenden - Attachment and Cognitive Psychotherapy

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Published by: JVolason on Mar 15, 2010
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07/21/2010

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The asterisks * refer to an accompanying PowerPoint presentation, to be found on
1
www.patcrittenden.com.Acknowledgments: I would like to thank Andrea Landini for his very helpful
2
comments on earlier drafts of this paper.
*Attachment and Cognitive Psychotherapy
1
Patricia M. CrittendenInvited AddressInternational Congress on Cognitive PsychotherapyGøtengorg, Sweden, June, 2005
2
AbstractAttachment and Cognitive PsychotherapyPatricia M. CrittendenLearning theory and it’s expansion as cognitive theory have revolutionized the formerlymurky and subjective field of psychotherapy by creating evidence-based, theoreticallyinformed psychotherapy. This talk focuses on how cognitive therapy might develop next,with an emphasis on contributions from attachment theory. These contributions are:functional diagnosis, affect and its contribution to self-protection, a model of psychologicalfunctioning and its relation to psychopathology; and a basis for selecting treatments such thatrisk of harm is reduced. Attachment theory points to perception of danger and protection of oneself from danger as central to psychopathology. Information processing suggests theindependent importance of temporal order and affect for generating self-protective strategiesthat are applied, adaptively and maladaptively, to life circumstances. Together these suggestgroupings of patients whose psychological and behavioral processes are functionally similar,even if their symptoms differ. Assessing patients in functional terms could lead to greater  precision in the application of treatments to patients. The notion of purposeful eclecticism isintroduced as a way to assess the effects of therapeutic techniques, thus increasing the rangeof tools available to therapists and the specificity of their application. Finally, the role of therapists as transitional attachment figures is considered.
 
ICCP: Invited address, p. 2The sign of a great thinker is not his conclusions, but rather his ability to elicit thinking inothers. I’ve been reading a lot about cognitive therapy recently and I am impressed by howAaron Beck’s clarity of thought elicits thought on my own part. Some of my thoughts are inthis talk - a talk that I hope will add to the dialogue between cognitive therapy andattachment theory.Learning theory and it’s expansion in cognitive therapy have revolutionized the murky andsubjective field of psychotherapy. They have created the possibility for evidence-based,theoretically-informed therapy. This talk will focus on how cognitive therapy might developnext, with a particular emphasis on what attachment theory might have to offer. A basicnotion is that good theory is never static, it always changes and grows - or its time passes andit withers away.There are several limits to the effectiveness of cognitive therapy as it is practiced now, eachof which creates an opening for further development. But first, let me say clearly that I amaware that “cognitive therapy” is many different things; for economy I must speak in general, but I know the shoe cannot fit every foot. Further, I know that many researchers andclinicians within cognitive therapy are pushing precisely the limits that I will mention. I willaddress some of these, but if I omit your favorite thinker - or you yourself - I hope you willunderstand that the constraints of 35 minutes are very great.*Let me address four limitations of cognitive therapy:*1. The focus on symptoms, symptom-based diagnosis, and treatments directed to symptomreduction;*2. An emphasis on behavioral and verbal/rational psychological processes to the relativeexclusion of affect;*3. Lack of a comprehensive model of psychological development and its relation to psychopathology;*4. Limited exploration of the possibility that psychotherapy could harm patients (as opposedto simply being ineffective).
*1. Symptoms
People usually seek therapy because they feel * distress. This is the central evidence thatsomething functions poorly in the person’s life - as experienced by the person him- or herself.
*
Often, however, therapists transform this signal into a list of symptoms that thenare condensed into a symptom-based diagnosis. Once this happens, the patient’s perspectiverisks being replaced by the therapist’s.In place of symptom diagnoses, the Dynamic-Maturational Model (DMM) of attachmenttheory offers
*
 
 self-protective strategies
(Crittenden, 1995, 1997a, 2000, 2002). Self- protective strategies permit us to look beyond symptoms to identify their 
 function
for the patient. In doing so, we need to keep in mind that each behavior can serve several different
 
functions. For example, a smile can invite closeness, hide anger, express embarrassment, or warn someone not to come closer. Focusing on the function of behavior can help to focustreatment on the reasons for the behavior.* As Jeffrey Young notes, cognitive therapy is successful in 70% of cases, but only in theshort-term. Symptoms reappear by 1 year post-treatment in 40% of successful cases (Young,Klosko, Weishar, 2003). That is, half of cognitive treatments are unsuccessful. Focusingtreatment on eliminating the *
reasons
for the symptoms might improve the success-rate.The DMM proposes that symptoms are part of self-protective strategies that were used to protect the self from danger in the past and are still used now in both truly threateningsituations and also misperceived threat. It is the latter,
misperceived threat that elicitsmaladaptive self-protection
, that is the basis for psychopathology.Therapy aimed at helping patients to more accurately identify threat and to organize moreeffective forms of self-protection might be more useful, in the long-term, than therapy toeliminate unwanted symptoms. Moreover, when symptoms are understood as being part of self-protective strategies, patients’ view of themselves as being “crazy” or “sick” istransformed to one of seeing themselves as * competent, but more competent at dealing withthreat than with safety. That is, the DMM offers a * strengths approach to treating psychological disturbance, as opposed to an approach organized around vulnerability.
*2. Affect
Cognitive therapy emphasizes temporal contingencies and causal relations, particularly thoseexpressed verbally, for example, “core beliefs.” Attachment theory treats this “cognitive”information as different and distinct from affect in evolution, in neurology, and inimplications for disorder and treatment of disorder.To understand the DMM perspective on cognition and affect, I must speak a bit aboutmemory systems. Endel Tulving’s work is central (Schacter & Tulving, 1994). Memorysystems can be thought of as different ways of transforming sensory stimulation to yieldinformation that can organize behavior.The “cognitive” memory systems are procedural and semantic memory. Both are familiar tocognitive therapists. *
 Procedural memory
refers to sensorimotor schemas derived from previously learned temporal contingencies (i.e., feedback) and applied automatically andwithout conscious thought or language. That is, procedural memory is re-active. It is learnedon the basis of experienced contingencies and, therefore, is precise and specific.
* Semantic memory
refers to generalized understandings of causal relations, expressedverbally. Semantic information can be generated directly from experience or “borrowed”from others, for example, from parents, based on what they tell children. Or 
therapists
, basedon what they tell patients. “Core beliefs” are an example of semantic information.Semantic statements include both generalizations about the past and prescriptions for thefuture. Semantic memory is the knowledge of (1) how it was as well as (2) what one
 should 
do or 
ought 
to do. The basis of a semantic statement is a when/then of if/then statement, but it

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