cognitive-behavioral therapy


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Related to cognitive-behavioral therapy: Cognitive behaviour therapy

Cognitive-Behavioral Therapy

 

Definition

Cognitive-behavioral therapy is an action-oriented form of psychosocial therapy that assumes that maladaptive, or faulty, thinking patterns cause maladaptive behavior and "negative" emotions. (Maladaptive behavior is behavior that is counter-productive or interferes with everyday living.) The treatment focuses on changing an individual's thoughts (cognitive patterns) in order to change his or her behavior and emotional state.

Purpose

Theoretically, cognitive-behavioral therapy can be employed in any situation in which there is a pattern of unwanted behavior accompanied by distress and impairment. It is a recommended treatment option for a number of mental disorders, including affective (mood) disorders, personality disorders, social phobia, obsessive-compulsive disorder (OCD), eating disorders, substance abuse, anxiety or panic disorder, agoraphobia, post-traumatic stress disorder (PTSD), and attention-deficit/hyperactivity disorder (ADHD). It is also frequently used as a tool to deal with chronic pain for patients with illnesses such as rheumatoid arthritis, back problems, and cancer. Patients with sleep disorders may also find cognitive-behavioral therapy a useful treatment for insomnia.

Precautions

Cognitive-behavioral therapy may not be suitable for some patients. Those who do not have a specific behavioral issue they wish to address and whose goals for therapy are to gain insight into the past may be better served by psychodynamic therapy. Patients must also be willing to take a very active role in the treatment process.
Cognitive-behavioral intervention may be inappropriate for some severely psychotic patients and for cognitively impaired patients (for example, patients with organic brain disease or a traumatic brain injury), depending on their level of functioning.

Description

Cognitive-behavioral therapy combines the individual goals of cognitive therapy and behavioral therapy.
Pioneered by psychologists Aaron Beck and Albert Ellis in the 1960s, cognitive therapy assumes that maladaptive behaviors and disturbed mood or emotions are the result of inappropriate or irrational thinking patterns, called automatic thoughts. Instead of reacting to the reality of a situation, an individual reacts to his or her own distorted viewpoint of the situation. For example, a person may conclude that he is "worthless" simply because he failed an exam or did not get a date. Cognitive therapists attempt to make their patients aware of these distorted thinking patterns, or cognitive distortions, and change them (a process termed cognitive restructuring).
Behavioral therapy, or behavior modification, trains individuals to replace undesirable behaviors with healthier behavioral patterns. Unlike psychodynamic therapies, it does not focus on uncovering or understanding the unconscious motivations that may be behind the maladaptive behavior. In other words, strictly behavioral therapists do not try to find out why their patients behave the way they do, they just teach them to change the behavior.
Cognitive-behavioral therapy integrates the cognitive restructuring approach of cognitive therapy with the behavioral modification techniques of behavioral therapy. The therapist works with the patient to identify both the thoughts and the behaviors that are causing distress, and to change those thoughts in order to readjust the behavior. In some cases, the patient may have certain fundamental core beliefs, called schemas, which are flawed and require modification. For example, a patient suffering from depression may be avoiding social contact with others, and suffering considerable emotional distress because of his isolation. When questioned why, the patient reveals to his therapist that he is afraid of rejection, of what others may do or say to him. Upon further exploration with his therapist, they discover that his real fear is not rejection, but the belief that he is hopelessly uninteresting and unlovable. His therapist then tests the reality of that assertion by having the patient name friends and family who love him and enjoy his company. By showing the patient that others value him, the therapist both exposes the irrationality of the patient's belief and provides him with a new model of thought to change his old behavior pattern. In this case, the person learns to think, "I am an interesting and lovable person; therefore I should not have difficulty making new friends in social situations." If enough "irrational cognitions" are changed, this patient may experience considerable relief from his depression.
A number of different techniques may be employed in cognitive-behavioral therapy to help patients uncover and examine their thoughts and change their behaviors. They include:
  • Behavioral homework assignments. Cognitive-behavioral therapists frequently request that their patients complete homework assignments between therapy sessions. These may consist of real-life "behavioral experiments" where patients are encouraged to try out new responses to situations discussed in therapy sessions.
  • Cognitive rehearsal. The patient imagines a difficult situation and the therapist guides him through the step-by-step process of facing and successfully dealing with it. The patient then works on practicing, or rehearsing, these steps mentally. Ideally, when the situation arises in real life, the patient will draw on the rehearsed behavior to address it.
  • Journal. Patients are asked to keep a detailed diary recounting their thoughts, feelings, and actions when specific situations arise. The journal helps to make the patient aware of his or her maladaptive thoughts and to show their consequences on behavior. In later stages of therapy, it may serve to demonstrate and reinforce positive behaviors.
  • Modeling. The therapist and patient engage in role-playing exercises in which the therapist acts out appropriate behaviors or responses to situations.
  • Conditioning. The therapist uses reinforcement to encourage a particular behavior. For example, a child with ADHD gets a gold star every time he stays focused on tasks and accomplishes certain daily chores. The gold star reinforces and increases the desired behavior by identifying it with something positive. Reinforcement can also be used to extinguish unwanted behaviors by imposing negative consequences.
  • Systematic desensitization. Patients imagine a situation they fear, while the therapist employs techniques to help the patient relax, helping the person cope with their fear reaction and eventually eliminate the anxiety altogether. For example, a patient in treatment for agoraphobia, or fear of open or public places, will relax and then picture herself on the sidewalk outside of her house. In her next session, she may relax herself and then imagine a visit to a crowded shopping mall. The imagery of the anxiety-producing situations gets progressively more intense until, eventually, the therapist and patient approach the anxiety-causing situation in real-life (a "graded exposure"), perhaps by visiting a mall. Exposure may be increased to the point of "flooding," providing maximum exposure to the real situation. By repeatedly pairing a desired response (relaxation) with a fear-producing situation (open, public spaces), the patient gradually becomes desensitized to the old response of fear and learns to react with feelings of relaxation.
  • Validity testing. Patients are asked to test the validity of the automatic thoughts and schemas they encounter. The therapist may ask the patient to defend or produce evidence that a schema is true. If the patient is unable to meet the challenge, the faulty nature of the schema is exposed.
Initial treatment sessions are typically spent explaining the basic tenets of cognitive-behavioral therapy to the patient and establishing a positive working relationship between therapist and patient. Cognitive-behavioral therapy is a collaborative, action-oriented therapy effort. As such, it empowers the patient by giving him an active role in the therapy process and discourages any overdependence on the therapist that may occur in other therapeutic relationships. Therapy is typically administered in an outpatient setting in either an individual or group session. Therapists include psychologists (Ph.D., Psy.D., Ed.D. or M.A. degree), clinical social workers (M.S.W., D.S.W., or L.S.W. degree), counselors (M.A. or M.S. degree), or psychiatrists (M.D. with specialization in psychiatry) and should be trained in cognitive-behavioral techniques, although some brief cognitive-behavioral interventions may be suggested by a primary physician/caregiver. Treatment is relatively short in comparison to some other forms of psychotherapy, usually lasting no longer than 16 weeks. Many insurance plans provide reimbursement for cognitive-behavioral therapy services. Because coverage is dependent on the disorder or illness the therapy is treating, patients should check with their individual plans.

Rational-emotive behavior therapy

Rational-emotive behavior therapy (REBT) is a popular variation of cognitive-behavioral therapy developed in 1955 by psychologist Albert Ellis. REBT is based on the belief that a person's past experiences shape their belief system and thinking patterns. People form illogical, irrational thinking patterns that become the cause of both their negative emotions and of further irrational ideas. REBT focuses on helping patients discover these irrational beliefs that guide their behavior and replace them with rational beliefs and thoughts in order to relieve their emotional distress.
There are 10 basic irrational assumptions that trigger maladaptive emotions and behaviors:
  • It is a necessity for an adult to be loved and approved of by almost everyone for virtually everything.
  • A person must be thoroughly competent, adequate, and successful in all respects.
  • Certain people are bad, wicked, or villainous and should be punished for their sins.
  • It is catastrophic when things are not going the way one would like.
  • Human unhappiness is externally caused. People have little or no ability to control their sorrows or to rid themselves of negative feelings.
  • It is right to be terribly preoccupied with and upset about something that may be dangerous or fearsome.
  • It is easier to avoid facing many of life's difficulties and responsibilities than it is to undertake more rewarding forms of self-discipline.
  • The past is all-important. Because something once strongly affected someone's life, it should continue to do so indefinitely.
  • People and things should be different from the way they are. It is catastrophic if perfect solutions to the grim realities of life are not immediately found.
  • Maximal human happiness can be achieved by inertia and inaction or by living passively and without commitment.

Meichenbaum's self-instructional approach

Psychologist Donald Meichenbaum pioneered the self-instructional, or "self-talk," approach to cognitive-behavioral therapy in the 1970s. This approach focuses on changing what people say to themselves, both internally and out loud. It is based on the belief that an individual's actions follow directly from this self-talk. This type of therapy emphasizes teaching patients coping skills that they can use in a variety of situations to help themselves. The technique used to accomplish this is self-instructional inner dialogue, a method of talking through a problem or situation as it occurs.

Preparation

Patients may seek therapy independently, or be referred for treatment by a primary physician, psychologist, or psychiatrist. Because the patient and therapist work closely together to achieve specific therapeutic objectives, it is important that their working relationship is comfortable and their goals are compatible. Prior to beginning treatment, the patient and therapist should meet for a consultation session, or mutual interview. The consultation gives the therapist the opportunity to make an initial assessment of the patient and recommend a course of treatment and goals for therapy. It also gives the patient an opportunity to find out important details about the therapist's approach to treatment, professional credentials, and any other issues of interest.
In some managed-care clinical settings, an intake interview or evaluation is required before a patient begins therapy. The intake interview is used to evaluate the patient and assign him or her to a therapist. It may be conducted by a psychiatric nurse, counselor, or social worker.

Key terms

Automatic thoughts — Thoughts that automatically come to mind when a particular situation occurs. Cognitive-behavioral therapy seeks to challenge automatic thoughts.
Cognitive restructuring — The process of replacing maladaptive thought patterns with constructive thoughts and beliefs.
Maladaptive — Unsuitable or counterproductive; for example, maladaptive behavior is behavior that is inappropriate to a given situation.
Psychodynamic therapy — A therapeutic approach that assumes dysfunctional or unwanted behavior is caused by unconscious, internal conflicts and focuses on gaining insight into these motivations.
Relaxation technique — A technique used to relieve stress. Exercise, biofeedback, hypnosis, and meditation are all effective relaxation tools. Relaxation techniques are used in cognitive-behavioral therapy to teach patients new ways of coping with stressful situations.
Schemas — Fundamental core beliefs or assumptions that are part of the perceptual filter people use to view the world. Cognitive-behavioral therapy seeks to change maladaptive schemas.

Normal results

Many patients who undergo cognitive-behavioral therapy successfully learn how to replace their maladaptive thoughts and behaviors with positive ones that facilitate individual growth and happiness. Cognitive-behavioral therapy may be used in conjunction with pharmaceutical and other treatment interventions, so overall success rates are difficult to gauge. However, success rates of 65% or more have been reported with cognitive-behavioral therapy alone as a treatment for panic attacks and agoraphobia. Relapse has been reported in some patient populations, perhaps due to the brief nature of the therapy, but follow-up sessions can put patients back on track.

Resources

Organizations

Albert Ellis Institute. 45 East 65th St., New York, NY 10021. (800) 323-4738. http://www.rebt.org.
Beck Institute. GSB Building, City Line and Belmont Avenues, Suite 700, Bala Cynwyd, PA 19004-1610. (610) 664-3020. http://www.beckinstitute.org.
National Association of Cognitive-Behavioral Therapists. P.O. Box 2195, Weirton, WV 26062. (800) 853-1135. http://www.nacbt.org.

therapy

 [ther´ah-pe]
activity therapy in the nursing interventions classification, a nursing intervention defined as the prescription of and assistance with specific physical, cognitive, social, and spiritual activities to increase the range, frequency, or duration of an individual's (or group's) activity.
aerosol therapy see aerosol therapy.
animal-assisted therapy in the nursing interventions classification, a nursing intervention defined as the purposeful use of animals to provide affection, attention, diversion, and relaxation.
anticoagulant therapy see anticoagulant therapy.
antineoplastic therapy see antineoplastic therapy.
antiplatelet therapy the use of platelet inhibitors such as aspirin, dipyridamole, or sulfinpyrazone, to inhibit platelet adhesion or aggregation and so prevent thrombosis, alter the course of atherosclerosis, or prolong vascular graft patency.
art therapy in the nursing interventions classification, a nursing intervention defined as facilitation of communication through drawings or other art forms.
aversion therapy (aversive therapy) a form of behavior therapy that uses aversive conditioning, pairing undesirable behavior or symptoms with unpleasant stimulation in order to reduce or eliminate the behavior of symptoms. The term is sometimes used synonymously with aversive conditioning.
behavior therapy see behavior therapy.
carbon dioxide–oxygen therapy see carbon dioxide–oxygen therapy.
chest physical therapy see under physical therapy.
client-centered therapy a form of psychotherapy in which the emphasis is on the patient's self-discovery, interpretation, conflict resolution, and reorganization of values and life approach, which are enabled by the warm, nondirective, unconditionally accepting support of the therapist, who reflects and clarifies the patient's discoveries.
cognitive therapy (cognitive-behavioral therapy) a directive form of psychotherapy based on the theory that emotional problems result from distorted attitudes and ways of thinking that can be corrected. Using techniques drawn in part from behavior therapy, the therapist actively seeks to guide the patient in altering or revising negative or erroneous perceptions and attitudes.
collapse therapy a formerly common treatment for pulmonary tuberculosis in which the diseased lung was collapsed in order to immobilize it and allow it to rest. pneumonolysis and thoracoplasty are methods still sometimes used to collapse a lung and allow access during thoracic surgery.
combined modality therapy treatment of cancer using two or more types of therapy, such as with chemoradiotherapy. Called also multimodality therapy.
compression therapy treatment of venous insufficiency, varicose veins, or venous ulceration of the lower limbs by having the patient wear compressing garments such as support hose.
continuous renal replacement therapy hemodialysis or hemofiltration done 24 hours a day for an extended period, usually in a critically ill patient.
convulsive therapy treatment of mental disorders, primarily depression, by induction of convulsions. The type almost universally used now is electroconvulsive therapy (ECT), in which the convulsions are induced by electric current. In the past, drugs were sometimes used.
couples therapy marital t.
diet therapy treatment of disease by regulation of the diet.
electroconvulsive therapy (ECT) (electroshock therapy) see electroconvulsive therapy.
endocrine therapy treatment of disease by means of hormones; called also hormonal or hormone therapy.
estrogen replacement therapy administration of an estrogen to treat estrogen deficiency, such as that occurring after menopause; there are a number of indications, including the prevention of postmenopausal osteoporosis and coronary artery disease, and the prevention and treatment of vasomotor symptoms such as hot flashes and of thinning of the skin and vaginal epithelium, atrophic vaginitis, and vulvar atrophy. In women with a uterus, a progestational agent is usually included to prevent endometrial hyperplasia. Called also hormone replacement therapy.
exercise therapy: ambulation in the nursing interventions classification, a nursing intervention defined as promotion of and assistance with walking to maintain or restore autonomic and voluntary body functions during treatment and recovery from illness or injury.
exercise therapy: balance in the nursing interventions classification, a nursing intervention defined as use of specific activities, postures, and movements to maintain, enhance, or restore balance.
exercise therapy: joint mobility in the nursing interventions classification, a nursing intervention defined as the use of active or passive body movement to maintain or restore joint flexibility.
exercise therapy: muscle control in the nursing interventions classification, a nursing intervention defined as the use of specific activity or exercise protocols to enhance or restore controlled body movement.
family therapy
1. group therapy of the members of a family, exploring and improving family relationships and processes, understanding and modifying home influences that contribute to mental disorder in one or more family members, and improving communication and collective, constructive methods of problem-solving.
2. in the nursing interventions classification, a nursing intervention defined as assisting family members to move their family toward a more productive way of living.
gold therapy chrysotherapy.
group therapy see group therapy.
helium-oxygen therapy see helium-oxygen therapy.
hemodialysis therapy in the nursing interventions classification, a nursing intervention defined as management of extracorporeal passage of the patient's blood through a hemodialyzer. See also hemodialysis.
hemofiltration therapy in the nursing interventions classification, a nursing intervention defined as cleansing of acutely ill patient's blood via a hemofilter controlled by the patient's hydrostatic pressure. See also hemofiltration.
highly active antiretroviral therapy (HAART) the aggressive use of extremely potent antiretroviral agents in the treatment of human immunodeficiency virus infection.
hormonal therapy (hormone therapy) endocrine therapy.
hormone replacement therapy the administration of hormones to correct a deficiency; usually used to denote estrogen replacement therapy occurring after menopause.
host modulating therapy efforts to control periodontal disease by directly targeting the host response; an example is the use of drugs that do this, such as sub-antimicrobial doses of doxycycline, nonsteroidal antiinflammatory drugs, or bisphosphonates.
humidification therapy (humidity therapy) the therapeutic use of air supersaturated with water to prevent or correct a moisture deficit in the respiratory tract; see also humidity therapy.
immunosuppressive therapy therapeutic immunosuppression.
inhalation therapy the term formerly used for respiratory care (def. 3).
intravenous therapy (IV therapy) in the nursing interventions classification, a nursing intervention defined as administration and monitoring of intravenous infusions of fluids and medications.
leech therapy in the nursing interventions classification, a nursing intervention defined as the application of medicinal leeches to help drain replanted or transplanted tissue engorged with venous blood.
marital therapy a type of family therapy aimed at understanding and treating one or both members of a couple in the context of a distressed relationship, but not necessarily addressing the discordant relationship itself. In the past, the term has also been used in a narrower sense to mean what is defined as marriage therapy, but that is increasingly considered a subset of marital therapy. Called also couples therapy.
marriage therapy a subset of marital therapy that focuses specifically on the bond of marriage between two people, enhancing and preserving it.
milieu therapy
1. treatment, usually in a psychiatric treatment center, that emphasizes the provision of an environment and activities appropriate to the patient's emotional and interpersonal needs.
2. in the nursing interventions classification, a nursing intervention defined as the use of people, resources, and events in the patient's immediate environment to promote optimal psychosocial functioning.
multimodality therapy combined modality therapy.
music therapy
1. the use of music to effect positive changes in the psychological, physical, cognitive, or social functioning of individuals with health or educational problems. Music therapy is used for a wide variety of conditions, including mental disorders, developmental and learning disabilities, Alzheimer's disease and other conditions related to aging, brain injury, substance abuse, and physical disability. It is also used for the management of acute and chronic pain and for the reduction of stress.
2. in the nursing interventions classification, a nursing intervention defined as using music to help achieve a specific change in behavior or feeling.
neoadjuvant therapy in single-agent therapy or combined modality therapy for cancer, initial use of one modality, such as chemotherapy or radiotherapy, to decrease tumor burden prior to use of another modality, usually surgery.
nutrition therapy in the nursing interventions classification, a nursing intervention defined as administration of food and fluids to support metabolic processes of a patient who is malnourished or at high risk for becoming malnourished. See also nutrition.
occupational therapy see occupational therapy.
optometric vision therapy a treatment plan prescribed to correct or improve specific dysfunctions of the vision system; it includes, but is not limited to, the treatment of strabismus (turned eye), other dysfunctions of binocularity (eye teaming), amblyopia (lazy eye), accommodation (eye focusing), ocular motor function (general eye movement ability), and visual-motor and visual-perceptual abilities.
oral rehydration therapy (ORT) oral administration of a solution of electrolytes and carbohydrates in the treatment of dehydration.
oxygen therapy see oxygen therapy.
peritoneal dialysis therapy in the nursing interventions classification, a nursing intervention defined as administration and monitoring of dialysis solution into and out of the peritoneal cavity. See also peritoneal dialysis.
physical therapy see physical therapy.
play therapy see play therapy.
pulp canal therapy root canal therapy.
PUVA therapy [psoralen + ultraviolet A], a form of photochemotherapy for skin disorders such as psoriasis and vitiligo; oral psoralen administration is followed two hours later by exposure to ultraviolet a radiation.
radiation therapy see radiation therapy.
recreation therapy in the nursing interventions classification, a nursing intervention defined as the purposeful use of recreation to promote relaxation and enhancement of social skills.
reminiscence therapy in the nursing interventions classification, a nursing intervention defined as using the recall of past events, feelings, and thoughts to facilitate pleasure, quality of life, or adaptation to present circumstances.
renal replacement therapy therapy such as hemodialysis or transplantation that takes the place of nonfunctioning kidneys. See also continuous renal replacement therapy.
replacement therapy treatment to replace deficient formation or loss of body products by administration of the natural body products or synthetic substitutes. See also replacement. Called also substitution therapy.
respiratory therapy respiratory care.
root canal therapy that aspect of endodontics dealing with the treatment of diseases of the dental pulp, consisting of partial (pulpotomy) or complete (pulpectomy) extirpation of the diseased pulp, cleaning and sterilization of the empty root canal, enlarging and shaping the canal to receive sealing material, and obturation of the canal with a nonirritating hermetic sealing agent. Called also pulp canal therapy.
shock therapy obsolete term for convulsive therapy.
simple relaxation therapy in the nursing interventions classification, a nursing intervention defined as the use of techniques to encourage and elicit relaxation for the purpose of decreasing undesirable signs and symptoms such as pain, muscle tension, or anxiety.
speech therapy the use of special techniques for correction of speech disorders.
substitution therapy replacement therapy.
swallowing therapy in the nursing interventions classification, a nursing intervention defined as facilitating swallowing and preventing complications of impaired swallowing.
thrombolytic therapy the administration of drugs for thrombolysis (dissolution of a thrombus in an artery), to reduce the size of occlusion and thereby reduce damage to muscular tissue; the coronary artery is a commonly used site. Agents commonly used are streptokinase and tissue plasminogen activator (t-PA).
thyroid replacement therapy treatment of hypothyroidism by administration of thyroxine, usually in the form of levothyroxine sodium. Called also thyrotherapy.
ultraviolet therapy see ultraviolet therapy.

cognitive-behavioral therapy (CBT),

a broadening of behavior therapy to include consideration of cognitive processes and use specific techniques for teaching cognitive skills that help the patient adaptively perceive, interpret, and respond to the environment.
See also: cognitive therapy, psychotherapy.

cognitive-behavioral therapy

(kŏg′nĭ-tĭv-bĭ-hāv′yə-rəl)
n.
A highly structured psychotherapeutic method used to alter distorted attitudes and problem behavior by identifying and replacing negative inaccurate thoughts and changing the rewards for behaviors.
References in periodicals archive ?
The randomized, single-blind trial compared patients receiving the brief cognitive-behavioral therapy with a control group of patients who received two sessions of basic instruction in sleep hygiene.
Behavioral and physical treatments, including relaxation training, thermal biofeedback combined with relaxation, EMG biofeedback and cognitive-behavioral therapy, or behavioral therapy plus preventive drug therapy are treatment options.
In a controlled 16-week trial of 127 subjects with depression and functional impairment caused by multiple sclerosis, the 62 subjects randomized to telephone-administered cognitive-behavioral therapy (T-CBT) showed greater improvement in major depressive disorder frequency (p = 0.
The intervention involved 12 weeks of optimized analgesic therapy combined with the teaching of pain self-management strategies, followed by an additional 12 weeks including adapted cognitive-behavioral therapy (JAMA Intern.
The results indicated that there was a significant difference between two experiment and control groups in the pre-test, posttest and the follow-up stage of mental health status; in fact, cognitive-behavioral therapy was effective in preventing relapse in addicted individuals.
Maxim said that in trauma-focused cognitive-behavioral therapy, the clinician tries to address cognitive distortions, which are misperceptions surrounding the trauma.
Child Study Center) outline an evidence-based individual cognitive-behavioral therapy approach that clinicians with a background in psychopathology, as well as psychologists, psychiatrists, social workers, psychiatric nurse practitioners, and other professionals, can use with children and adolescents (ages eight to 16) experiencing anger, aggression, irritability, and noncompliance problems.
Major Finding: Prolonged exposure and cognitive-behavioral therapy were significantly more effective than was escitalo-pram in reducing the incidence of posttraumatic stress disorder (21%, 23%, and 24%, respectively), but patients treated immediately and 5 months after the traumatic event responded similarly well to treatment.
Making cognitive-behavioral therapy work; clinical process for new practitioners, 2d ed.
The Additive Benefit of Hypnosis and Cognitive-Behavioral Therapy in Treating Acute Stress Disorder.
Mexico border, the effect of varenicline on learning deficits caused by nicotine withdrawal in mice as well as the effect of denicotinized cigarettes on smokers' brains, how family-based intervention helps male children of drug users, computerized cognitive-behavioral therapy and its effect on drug use, and how vigabatrin prevents relapse to methamphetamine use in an animal addiction model.