Cognitive Behavioral Therapy

Abstract

Human habits can be described by a variety of biological, psychosocial, and ecological factors communicating on a person with time. The worths, beliefs, and objectives that identify the habits one engages in are established through cognitive procedures unique to each individual as a result of the interplay between previous learning and the abovementioned aspects. When thought about together, the Model of Human Profession and Cognitive Behavioral Therapy offer a description for this view of human behavior. These frames of referral are reviewed in concerns to their conceptions of behavior, dysfunction, treatment approach, and their significance to occupational treatment.

Cognitive-Behavioral Treatment and the Design of Human Profession

Male is an open system that can alter and develop through interaction with the environment. Habits is an expression of psychosocial, biological, and ecological factors connecting within the system. Biological elements may incline someone to a certain illness or dysfunction which may be expressed in the presence of tension. Aspects such as household structure, workplace, and culture can contribute to favorable or unfavorable experiences from which an individual discovers.

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There is an innate drive within human beings for self-efficacy; the supreme objective is to master one's environment. An individual's worths, beliefs, and objectives determine the habits one engages in to accomplish the ultimate goal of ecological mastery.

These values, beliefs, and goals are developed through cognitive processes unique to each individual and are a result of the interplay between previous learning and psychosocial, biological, and environmental factors throughout life. Because each person's cognitive processes are unique, experiences are subjectively interpreted in different ways.

People react in context with their desire for environmental mastery and their personal beliefs and values learned throughout life. When considered together, the Model of Human Occupation and Cognitive-Behavioral Therapy frame of reference give an explanation of behavior that includes psychosocial, biological and environmental factors while maintaining the importance of cognition. The purpose of this paper is to review how Cognitive-Behavioral Therapy and the Model of Human Occupation explain behavior, dysfunction, treatment approach, and their relevance to occupational therapy.

Theory

Kielhofner and Burke's Model of Human Occupation (MOHO) (1980) believes that humans have an innate drive for exploration and mastery of their respective environments. Man interacts with the environment though engagement in occupation. Occupations are the means through which an individual pursues their goals. Within this model, occupations are defined as complex, organized groups of goal-oriented behaviors (Bruce & Borg, 1993). One's chosen actions and occupations are a meaningful reflection of personal beliefs and goals for environmental mastery. Mastery is the extent to which an individual perceives the result of their behavior as effective, efficient, and satisfying (Stein & Cutler, 1998).

MOHO postulates an open systems theory in regards to human behavior. "An open system is an organized complex of subsystems that are in dynamic interaction. The system is, in turn, in dynamic interaction with its environment. All parts are maintained and transformed through this dynamic interaction" (Kielhofner & Burke, 1980, p. 573). The open system interacts with the environment through a process of input, throughput, output, and feedback. Input is information from the environment; throughput is the processing of input by the internal cognitive structures of a human; output is the mental, physical, and social aspects of behavior; and feedback is information from the environment about the consequences of a behavior (1980).

The open system can be divided into a hierarchical arrangement of three subsystems that are responsible for behavior. The highest level governing over behavior is volition. This is the underlying, energizing component behind behavior responsible for which one will be chosen and initiated. Volition is determined by one's innate drive to master his/her environment, as well as his/her beliefs surrounding a behavior (Bruce & Borg, 1993). Personal causation, values, and interests comprise volition. Personal causation is the motivation and expectations surrounding a behavior. It incorporates past successes and failures to form images of self-efficacy. Values represent the importance of certain behaviors to an individual. Interests are determined by the pleasure one derives from engaging in a specific occupation (Kielhofner & Burke, 1980).

Volition is believed to govern over the lower subsystems of the hierarchy (Kielhofner & Burke, 1980). The middle subsystem is defined as habituation. Habituation is responsible for organizing behavior into roles, patterns, and routines. Roles reflect a group of behaviors with which an individual may have certain expectations of performance. The individual's beliefs and society influence these expectations. Roles contribute to self-identity and influence behavior. This organization allows for certain behaviors to be performed automatically and adapted to various environments. Performance, the lowest subsystem within the hierarchy, consists of the skills necessary for producing behavior. These include perceptual-motor processing skills, cognition, and communication. The function of the performance subsystem is to produce behaviors called upon by volition and habituation, which are located higher in the hierarchy of the human system (Bruce & Borg, 1993).

MOHO's governing subsystem, volition, can be compared to the concept of cognition described by the Cognitive-Behavioral Therapy frame of reference. Through this comparison, Cognitive-Behavioral Therapy (CBT) provides an explanation for the acquisition and structure of volitional system. The major theorists under CBT believe that cognitive structures such as beliefs, thinking styles, problem-solving styles, and coping styles as well as the environment are the determinants of behavior (Johnston, 1987). The above structures are represented by a schema, which is developed through reactions to social, environmental, and genetic influences over time. A schema is defined as the global cognitive processes associated with past experience (Bootzin, 1988). Schema can be influenced by positive and negative experiences, such as culture, family structure, and social roles. Another assumption of CBT is that people are capable of guiding the course of their lives via their thoughts. Ellis, as cited in Barris, Kielhofner, and Watts
(1988), believes that "humans are responsible for their emotions and behavior, as having the potential to create personal meaning, and as behaving in ways influenced by thought processes rather than determined by unconscious forces" (p. 92). The concept of personal responsibility for behavior is also incorporated into MOHO through the volitional system. This subsystem is responsible for choices regarding behavior.

According to CBT theorists, the cognitive events responsible for behavior are learned. Albert Bandura's theory of social learning explains how learning impacts cognition and behavior. Learning is seen as an outcome of the interaction between behavior, person, and environment. People choose behaviors based on expectancy, or what they anticipate will happen if a behavior is performed. Therefore, individuals are more likely to perform a specific behavior if they believe the results will lead to something they want (Bruce & Borg, 1993). Personal causation, a component of volition, is responsible for expectancy and links Bandura's theory to MOHO. Reinforcement influences whether behaviors are performed. These can be external, vicarious or self-produced. External reinforcement comes from the environment in many forms, including social praise/acceptance, rewards, privileges or penalties.

Vicarious reinforcement is the individual's values and previously learned images of success or failure associated with a particular behavior. Self-produced reinforcement involves the interpretation of a behavior as satisfying or unsatisfying. Personal satisfaction is seen as the best reinforcement for behavior (1993). Thus, behavior is driven by the goal of self-efficacy, an idea shared by MOHO. This feeling of satisfaction after occupational performance develops into a sense of effectiveness. Satisfaction alters CBT's cognition and MOHO's volitional subsystem, making it more likely for a behavior to occur again. Bandura explains that personal experience, modeling, and observational learning are ways behaviors are acquired.

Cognition plays a major role in the selection of behaviors because people will repeat behaviors they believe will have positive outcomes (Cole, 1998). Cognitive appraisal is the internal processing, which occurs between the stimulus and response. Behaviors are elicited after this cognitive appraisal occurs. One's beliefs and values are derived from the cognitive appraisal of events over time (Bootzin, 1988). The process of cognitive appraisal is synonomous with MOHO's concept of throughput, a process that also elicits behaviors. Some behaviors performed daily over time do not require extensive cognitive appraisal. Aaron Beck describes these behaviors as automatic thoughts (Bruce & Borg, 1993). People do not recognize the problem-solving and internal cognition associated with these automatic thoughts. Automatic thoughts are closely related to the habituation subsystem in MOHO.

Behavior Change

Within the human system, each subsystem and the environment are interdependent. A disturbance in functioning in one of the subsystems will affect all the subsystems requiring the person to adapt to the resultant changes. The system changes throughout a lifetime to respond to the changing demands and expectations of the environment (Kielhofner & Burke, 1980). Restructuring or restoration of any of the internal subsystems as well as the environment can mediate behavior change. The process of feedback informs the system of the consequences of behavior. During feedback, actual performance is compared to the expected outcome, which helps the system adjust its performance and restructure the internal hierarchy. Feedback also shapes self-images created by the personal causation component (1980). Treatment can target behavior change directly at the volitional level by changing the cognitive structures associated with personal causation, values, and interests thereby affecting the lower levels of the system. Other levels may be impacted through environmental modification or increasing occupational performance by strengthening performance components or improving habits. Improving performance will alter one's perception of the effectiveness of a behavior, thereby changing volition (Bruce & Borg, 1993).

In the healthy, well functioning individual, the volitional level governs behavior. Comparisons could be made between MOHO and CBT over the role volition and cognition play in the acquisition and determination of behavior. CBT's central tenet states that behavior change occurs only when the beliefs surrounding the behavior are altered. Similarly, MOHO's construct of personal causation represents the beliefs surrounding a behavior. Cognition allows man to regulate his behavior. Behaviors are determined by one's expectations of the outcome and efficacy of a behavior, therefore the thoughts behind expectations must change for behavior to change. According to Bandura, self-produced reinforcement is the most effective way to change expectancy. This requires observational learning or participation in an activity, in which the consequences of behavior are perceived to be successful, thus changing one's expectations about the effectiveness of that behavior. Other CBT theorists, such as Beck and Ellis believe people can be taught to view the world in a more accurate way, which alters behavior. This approach targets changes in behavior through the alteration of irrational thinking patterns. This involves evaluation of the validity of thoughts; formulation of new, more rational thoughts; and practice of the new thinking styles (Bruce & Borg, 1993).

Depression

According to MOHO, when considering a dysfunction such as depression, the individual must be viewed holistically to determine where in the open system a breakdown has occurred. Because the subsystems are interdependent, the depressed feelings may be caused by a disturbance in any of the subsystems or the environment. This disturbance will subsequently affect engagement in occupation. Disruptions of occupational performance due to biological dysfunction, harsh environmental circumstances, or a negative schema are possible explanations for depression according to this frame of reference. Unrealistic expectations or imbalance of roles within the habituation system may also lead to dysfunction (Kielhofner & Burke, 1980). The factors mentioned above lead to disturbance in occupational behavior causing the feelings of depression and incompetence. For example, a physical disability may alter a client's performance of important occupations, thereby affecting their expectations, beliefs, habits, and roles surrounding the behavior. If the client perceives the performance as negative, motivation regarding the behavior will decrease, interests will change and a negative self-image may occur within the volitional system.

An eclectic approach to treatment is required due to the many factors influencing behavior (Miller, et al, 1988). It may be appropriate to concentrate on negative beliefs within the volitional system, or on a lower subsystem that is disrupted, causing the negative feelings to occur. Environmental modification or improvement in the performance or habituation subsystems may help bring forth changes in volition by improving expectancy. It is necessary to consider occupational performance because engagement in occupation is meaningful to the individual and the means through which one pursues his/her goals. Occupational analysis, an evaluation technique, identifies where the disturbance in an occupation occurs. The steps include "observation of the environment, evaluation of how an occupation can promote a sense of purpose and identify one's values and interests, anticipation of how occupation contributes to goal fulfillment, consideration for the performance skills required to engage in the occupation, and evaluation of the balance of work, play and daily living tasks" (Bruce & Borg, 1993).

The application of CBT to treatment for a depressed individual may help restructure volition. According to CBT theorists, faulty, irrational thinking and inaccurate self-perception cause dysfunction. It is assumed that people can control their cognition; therefore, self-regulation of behavior, thoughts, and feelings through the use of logic and deductive reasoning is possible (Cole, 1998). Consequently, it would be necessary to aim treatment of a depressed individual at cognitive restructuring. Beck hypothesizes that dysfunction is caused by "automatic thoughts, which reflect habitual errors in thinking" (Cole, 1998, p. 131). Depression is thought to be the result of the "cognitive triad": self-devaluation, negative view of life experiences and a pessimistic view of the future (Bootzin, 1988). The rationale of Beck's cognitive therapy is that behavior change comes from cognitive change.

Therapy focuses on alteration of negative schema including identification of negative thoughts, evaluation of their validity, formulation of more realistic, positive responses and modification of the dysfunctional attitudes that underlie the negative thoughts. The Socratic method is utilized to allow the individual to discover the irrational beliefs for themselves (Bruce and Borg, 1993). Specific techniques include development of assertive beliefs, identification of personal rights, thought-stopping, role reversal, and symbolic modeling. By improving one's performance and thoughts behind behavior, self-produced reinforcement can occur, thus changing beliefs about that behavior (1993).

In a longitudinal study of newly injured persons with spinal cord injury (Craig, Hancock, Dickson, & Chang, 1997), levels of depression were compared between groups receiving CBT services in addition to traditional rehabilitation services to those who received no CBT during hospitalization. A psychologist and occupational therapist provided CBT to small groups over a ten-week period. Topics addressed during CBT included anxiety, depression, self-esteem, assertion, sexuality, and family relations. The therapists utilized cognitive restructuring techniques, relaxation, deep-breathing exercises, and visualization. From the follow-up measures of the patients one year post-treatment, the researchers found that the treatment group had greater levels of improvement in depression scores over time in comparison to the controls. It was also found that those with the highest levels of depression before treatment were significantly less depressed one year after treatment. The authors concluded that while not every person with spinal cord injury needs CBT, those with high levels of depression may benefit the most from CBT.

Application to Occupational Therapy

According to MOHO, a person interacts with the environment through engagement in occupation. MOHO and the professions of occupational therapy believe that engagement in occupation mediates change in capacities, beliefs, and occupational roles (Stein & Cutler, 1998). Assessment should include the subsystems, the feedback loop, organization of occupations in life, and the environment. Thorough assessment will assist the OT in developing a picture of occupational function and dysfunction as well as treatment goals (Miller, et al., 1988). MOHO provides a framework for an occupational therapist to find an explanation for occupational function and dysfunction. The OT should apply whichever theories, modalities, and facilitative activities that best meet the treatment goals of the individual, however goals should reflect the client's values.

A case study by Pizzi (1990) examined the clinical application of MOHO to treatment of an adult with AIDS. The physical, psychosocial, and environmental dysfunctions encountered by persons with HIV and AIDS affect all aspects of a person's occupational functioning. Therefore, a comprehensive assessment of the subsystems within the human system as well as the environment was required. This assessment allowed for the formulation of a treatment plan that met the complex needs of the client with AIDS. This case study shows how MOHO acts as a framework for a therapist to picture a client holistically when determining function and dysfunction, but does not necessarily prescribe a specific treatment technique.

CBT fills the gaps left by MOHO in outlining specific treatment approaches in regards to disturbances in cognition. Mahoney, as cited in Barris, Kielhofner, and Watts (1998), states that when following the CBT frame of reference, "the resultant task of the therapist is that of a diagnostician-educator who assesses maladaptive cognitive processes and subsequently arranges learning experiences that will alter cognitions and the behavior and affect patterns with which they correlate" (p. 90). An occupational therapist coming from CBT frame of reference should evaluate person-environment match; self-image, goals, and self-acceptance; the client's view of the environment; learning style and appropriate reinforcements; and environmental expectations and demands to help in the development of treatment goals (Cole, 1998). The goals set in treatment can serve as guidelines for clients to monitor their self-regulation and measure progress (1998). CBT relates to the practice of occupational therapy in that "cognitive behavioral skills may not be the traditional skills associated with occupational therapy, but they involve basic interpersonal skills, problem-solving skills, and self-management skills. As such, they are often prerequisites to the ability to perform effectively in the roles of player, student or worker" (Johnston, 1987).

Johnston outlined how an occupational therapist might use a CBT approach. Acting as an educator/facilitator, the OT would target skills such as problem solving, communication, and assertiveness. Techniques for treatment include the breakdown of skills into simpler steps, client examination of thoughts and assumptions regarding the skills, teaching of new skills, and practice of the skills (1987).

Social learning theory provides a treatment model for occupational therapy. Bandura's philosophy agrees with the logic of occupational therapy, "doing facilitates change" (Bruce & Borg, 1993, p. 211). According to Bandura, reinforcement is what motivates learning. OT's must determine the level of reinforcement and motivation required by each client for effective learning to occur (Cole, 1998). Engagement in activities allows clients to change thoughts of themselves from incapable to capable. By grading these activities, mastery of simple tasks occurs before difficult tasks are attempted. This grading allows the client to develop feelings of competence. These feelings of competence are self-reinforcing, which is in concordance with the

highest level of reinforcement identified by Bandura (1998).

Yakobina, Yakobina, and Tallant (1997) discussed how an occupational therapist might apply the CBT frame of reference to the treatment process of women with dysthymic disorder. The OT would act as an educator and emphasize the therapeutic use of pleasurable activities during treatment. The therapist would attempt to change negative thought patterns and facilitate the development of problem solving skills necessary to cope with daily activities by engaging in role-playing, group discussions, and homework assignments. In addition to traditional CBT techniques, engagement in occupation would allow the depressed person to test the validity of her negative assumptions.

Conclusion

As reviewed in this paper, the MOHO and CBT frames of reference both view behavior as the result of the interaction between a person and their environment. The complex interplay between biological, psychosocial, and environmental factors influences the way people view themselves and the world. Those cognitive processes determine what behaviors a person will engage in, as well as how the consequences are interpreted. Lazarus, as cited in Johnston (1987), explains the interaction between cognition and the environment, "the way a person moves or behaves can be adversely influenced by emotions, sensations, and the way people behave toward them. Conversely, if a person changes some aspect of his behavior, this change will alter his cognitions, emotions, sensations, and self-image" (p. 73).

Together, MOHO and CBT provide a way to understand behavior and how change occurs. MOHO acts as a framework for understanding the interdependent nature of humans and their environment. CBT provides an explanation for the cognitive processes seen by both frames as the commanding structures over behavior, as well as several treatment approaches to induce change in behavior. Applying the two frames of reference when formulating a treatment approach allows the therapist to individualize treatment while considering the multi-faceted nature of humans. Additionally, both frames see the engagement in occupation as an important mediator of change in the treatment process.

References

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