Abstract
Cognitive behavioural therapy (CBT) is an umbrella term, including several related theoretical models each with its own approach and techniques. This chapter will give an overview of the history of CBT, its underlying principles, therapeutic models, treatments and applications. It will also include a brief outline of dialectical behavioural therapy (DBT).
The fundamental tenet of CBT is that the way we think affects the way we feel and act. This deceptively simple statement has profound implications in practice. It means our distress could be modified by changing the way we think, or changing the way we respond to our thoughts.
Introduction
Cognitive behavioural therapy (CBT) is an umbrella term, including several related theoretical models each with its own approach and techniques. This chapter will give an overview of the history of CBT, its underlying principles, therapeutic models, treatments and applications. It will also include a brief outline of dialectical behavioural therapy (DBT).
The fundamental tenet of CBT is that the way we think affects the way we feel and act. This deceptively simple statement has profound implications in practice. It means our distress could be modified by changing the way we think, or changing the way we respond to our thoughts.
The roots of CBT lie in both behavioural and cognitive theories. The focus is on observable aspects of behaviour as distinct from therapies that seek to explore unconscious mechanisms.
First Wave: Behavioural Therapy
Early behaviour therapy was based on Pavlov’s classical conditioning theory. Here, learning was seen as a process of forming association between stimuli and response. A series of famous experiments followed. In 1920, John Watson (known as the father of behaviourism) experimentally induced phobia in nine-month-old Little Albert. A loud bang was made whenever Albert touched a white rat. Eventually, Albert began to show persistent fear of the white rat and later, to other furry objects.
In 1924, Mary Cover Jones, an American psychologist referred to as the mother of behaviour therapy by Joseph Wolpe (his contribution is discussed below) for her pioneering contribution to the field, worked with a young child, Peter, who was afraid of rabbits. While Peter was having his favourite food, Mary brought the rabbit close to him. Through repeated pairing and by process of counter-conditioning, Peter’s fear was gradually overcome, a process subsequently referred to as desensitisation. Interestingly, Peter’s fear was less when he saw other children playing with the rabbit. It was also less when he was with a supportive adult. These early observations of observational learning and the role of therapeutic relationship would be further elaborated by Albert Bandura in his Social Learning Theory in the 1970s.
In the 1940s, B F Skinner, another American psychologist, formulated operant conditioning theory. He argued that all organisms were influenced by the consequences of their own behaviour. The environment (situation or event) acts as cue for a particular behavioural response. If the consequence of the behaviour is positive, there will be an increase in the behaviour. If the consequence is negative, the behaviour would reduce in frequency. This means behaviour could be shaped through environmental manipulation and learning occurs by reinforcement.
The journal entry below is by a patient with symptoms of post-traumatic stress disorder (PTSD) following a car accident. Having had to undergo a number of operations for the injuries sustained, she developed a fear of hospitals, which impacted on her further treatment.
At work: My new manager wears same perfume as Dr X used to wear when I was in hospital. As soon as I could smell it, my heart started racing and then I became restless. I logged off the computer, grabbed my belongings and left the office. I went for a coffee and kept thinking to myself how ‘stupid’ I was being. I was scared of the smell of somebody’s perfume!
I was angry with myself for being so stupid, so I went to the gym to release my frustration.
Here, the smell of perfume elicits severe anxiety through classical conditioning. Leaving the situation resulted in reduced fear, which is a positive consequence. This consequence reinforces further avoidance behaviour through operant conditioning.
Functional Analysis of Behaviour: The ABC Model
Within a behaviour therapy approach detailed analysis of antecedents (A), behaviour (B) and consequences (C) is necessary to identify the cause–effect links, which may be hidden. Information can be gained from interview, self-monitoring and behavioural observations.
Problems and Goals
In behaviour therapy, problems have to be defined clearly. This will help to set specific, measurable, achievable, realistic and time bound goals.
Antecedents: Where did this happen? Who was around? When? What was happening before the problem? What were the external triggers? Any internal triggers such as thoughts, mood or bodily symptoms?
Behaviours: Get a step by step account. What did you do? How long this behaviour continue? When did it stop? What made it stop?
Consequences: What was the outcome? Did it cause further difficulties? Was there anything slightly good? Did it give you any benefits at all? What did others do? How did it feel afterwards? Did it help with your problems?
Functional Analysis, which seeks to establish the relationship between stimuli and responses, can inform understanding of behaviour and lead to interventions, by changing antecedents, behaviour and/or consequences as the examples below illustrate.
Changing Antecedents
When we can identify the antecedents to behaviour (Table 7.1), then these could be avoided, reduced or modified.
Table 7.1 Antecedents to behaviour
| Condition | External triggers | Internal triggers |
|---|---|---|
| Alcohol use | Drinking partners, weekends, pay day |
|
| Binge eating |
|
|
Changing Behaviour
When antecedents could not be changed, we can choose to behave differently with an alternate response which is pleasant (e.g. going for a walk, talk to someone, exercise, relaxation, hot bath) or necessary (cleaning etc.). Delaying problematic behaviour through different activities often reduces the urge to do it.
Changing Consequences
Changing consequences may involve rewarding positive behaviour, or adding a negative consequence, when undesired behaviour occurs. For example, using Star Charts (giving a star for positive behaviour) in children encourages further positive behaviour. Time out (placing in a low stimulus unrewarding environment, when the child misbehaves) reduces frequency of misbehaviour.
When used in therapy, the consequences are set by the therapist and clearly explained to the patient as in contingency management.
Contingency Management is used to shape adaptive behaviour or reduce problematic behaviour. These take the form: ‘If you do action X, then consequence Y would follow’. For example, making a behavioural contract between patient and therapist and following it consistently – such as if the patient phones over x times inappropriately, they lose the right to call the therapist in the next week. The therapist would reinforce adaptive or desired behaviours. The most powerful positive reinforcers are often expressions of the therapist’s approval, care and concern. Treatment developed from some of these ideas include:
Token Economy: in the 1950s patients with negative symptoms of schizophrenia in state hospital settings were rewarded with tokens when they engaged in ‘desired behaviours’ such as improved self-care. The tokens could be exchanged for rewards, mostly cigarettes
Aversion therapy: painful stimuli such as electric shocks or emetic medications were paired with undesirable behaviour (alcohol, drugs or deviant sexual interests). The expectation, based on classical conditioning theory, was to create an aversive conditioned response
Long-term effectiveness of Token Economy and Aversion therapy was poor and ethical considerations also led to its withdrawal.
Interestingly, alcohol consumption on disulfiram treatment creates an unpleasant and aversive physical reaction and the patients stop drinking to avoid the negative consequence. This can be seen as pharmacological aversion therapy.
Behavioural Interventions for Anxiety
Systematic Desensitisation (SD) was developed by Joseph Wolpe, a South African psychiatrist in the 1950s, based on reciprocal inhibition theory. For example, relaxation and fear could not co-exist at the same time due to the relaxation response inhibiting the anxiety response.
SD involves three phases: relaxation training, constructing anxiety hierarchy and desensitisation proper. A hierarchy of fearful scenes from minimum to maximum on a 0–100 scale will be constructed with the patient. Desensitisation is carried out by the patient visualising the least anxiety-provoking scene while deeply relaxed. When the patient can do this without anxiety, the patient moves to the next item in the hierarchy and proceeds ultimately to the top item of hierarchy.
SD is not used now as it is very time-consuming and more effective techniques such as Gradual Exposure (GE) became available. SD was done in imagination through visualisation, but in GE, exposure in visualisation and real situations is done. In GE, anxiety hierarchy is used, but relaxation is not used (see Table 7.2).
Table 7.2 Example of anxiety hierarchy in two patients
|
|
|
| Using a public toilet in a hospital | 100 | Attending hospital appointment |
| Using a public toilet | 80 | Inside the hospital – not attending appointment |
| 60 | In hospital grounds | |
| 50 | Hospital car park | |
| Using toilet at friends | 40 | Thought of going into hospital |
| 30 | Hospital appointment letter | |
| Using toilet at home | 20 | Picture of local hospital |
Implosive therapy and Flooding were used in the 1960s and 1970s. This involved exposure to extreme fear-provoking imagery or situation for an extended period, without hierarchy or relaxation. It was difficult for most patients to do due to intense fear and is no longer recommended. For example, in flooding, a person with fear of heights may be brought to the top of the building and asked to remain there till anxiety subsides over time.
Gradual Exposure involves provoking anxiety in a graded manner and allows it to decrease naturally, without avoidance, distraction, neutralisation, relaxation or other safety-seeking behaviours. Reduction in anxiety is through the process of repeated exposure (habituation) where gradually the anxiety is totally dissipated (extinction).
Exposure can be in imagination or in real situations (exposure in vivo). The sessions are planned in advance collaboratively and controlled with regard to difficulty or distress levels. Patients are asked to rate their subjective anxiety on a scale of 0–100 at 15-minute intervals. Typically, sessions last 30–60 minutes at a time. Prolonged exposure sessions are better. Exposure is terminated when anxiety is decreased to a mild to moderate level (30–50/100), that is, when ‘extinction’ has occurred. The exposure has to be repeated in between sessions, through homework assignments.
A single session of prolonged exposure can dramatically reduce phobias of small animals, snakes, injections etc. In panic disorder, exposure to the patient’s own interoceptive cues, or bodily signals of anxiety, is a key component of treatment. Physical symptoms of panic are deliberately provoked, such as exercise to increase heart rate or spinning in a chair to provoke dizziness. The exposure in obsessive compulsive disorder (OCD) is to the intrusive thought, object or action that triggers obsession. Exposure is combined with response prevention, that is the patient is not allowed to do any compulsion, neutralisation or compensatory action to defuse anxiety for 30–60 minutes. In PTSD, the patient’s detailed verbal narrative of trauma itself is the exposure. Retelling and re-experiencing help to desensitise the fear evoked by the memories and flashbacks.
Behavioural Therapy for Depression
Early behavioural theories in the 1970s conceptualised depression as a behavioural response to aversive events or the absence of pleasant events. In therapy, patients were encouraged to generally increase activities believed to be positive or enjoyable. This generalised approach was less effective, as it ignored the reinforcement value of specific activities for the person, such as avoidance of the aversive stimulus.
Behavioural Activation (BA) is an evidence-based treatment for depression, based on behavioural theory. Depression often leads to inactivity and rumination which leads to further depressed mood. The main goal is to change avoidant coping and behavioural patterns that maintain depression.
An increase in pleasurable activities is not the main goal in BA, but it is often a consequence of BA. The first step is to monitor activities on an hourly basis. This helps to educate the patient about links between inactivity and depressed mood. The next step is to schedule activities. Once completed, rate whether activities brought a sense of achievement or pleasure. The third step would be to develop a hierarchy of activities in a systematic manner, based on the person’s values, ranked from easy to difficult. The activities should be tangible and measurable, for example going for a walk for 30 minutes in the park, rather than abstract or cognitively oriented, for example thinking about a happy time in life. Scheduling valued activities and monitoring the outcome are important to keep the momentum. Progress is monitored systematically through objective measurements, for example keeping a record of positive activities.
Second Wave: Cognitive Therapy (CT)
Early behaviour therapists focussed on specific, measurable behaviour and the environmental reinforcements of the behaviour. Early behavioural therapists were suspicious of mentalistic concepts, such as the one used by psychoanalysts (e.g. ego, superego etc.) and this suspicion extended to patients’ explanations about their own behaviour, which were thought to be unreliable and unverifiable. However, the ‘cognitive revolution’ in psychology in the late 1960s brought about evidence of cognitive processes in human behaviour. The paradigm shifted from a reinforcement model to an information processing model. In addition, early proponents of combined cognitive behaviour techniques reported success through cognitive techniques.
The philosophical origins of CT can be traced to Stoic philosophy and Buddhism. Both regarded role of thought as fundamental in creating negative emotional states.
In the late 1950s and early 1960s, Albert Ellis’s Rational Emotive Therapy (RET) and his ABC model (Antecedents–Beliefs–Consequences) focussed on the central role of irrational thinking in needless human suffering. Ellis posited a general model of psychopathology, by listing a set of common irrational ideas (example – one should be thoroughly competent, adequate and perfect to be worthwhile). In therapy, Ellis challenged and confronted the patient’s illogical beliefs robustly.
In the late 1960s, Aaron Beck, a trained psychoanalyst became more interested in the conscious thoughts that lead to emotional distress. The cognitive model proposed by Beck states incorrect maladaptive beliefs and/or biased information processing are central in maintaining emotional distress. Systematic biases in thinking results in inaccurate perceptions of objective reality. Beck’s model identified specific and idiosyncratic thoughts rather than general irrational beliefs, as posited by Ellis.
Beck described three levels of thoughts.
Core Beliefs: deeply held, dominant beliefs about self, others and the world (e.g. I am worthless, I am unlovable, people are cruel, life has no meaning). They develop from significant life experiences, often from childhood. They may remain dormant, until they get activated by significant events.
Intermediate Beliefs: these are silent underlying assumptions, attitudes and rules that guide life. These rules (I must be perfect) and conditional statements (If I am not perfect, then I would not be respected) operate to overcome the pain of negative core beliefs. But in the long term, these beliefs are maladaptive because they are rigid, extreme and inflexible.
Negative Automatic Thoughts: they are experienced in a specific situation as seemingly plausible ideas, but in reality, they are exaggerated or false. They may reflect underlying core beliefs. For example, a woman with a core belief (I am unlovable), encounters her old class mate who does not smile at her (activating event) and then thinks ‘She does not like me’, ‘I can’t live like this’ and experiences sadness.
Key Aspects of CBT
Socratic dialogue is a distinctive method of CT to encourage learning through self-discovery. The therapist would ask questions about how the patient has come to a particular thought or belief, their reasons to think it is true and whether they could find anything that does not fit their belief. At the initial stage, there should be no prejudgement about thoughts being irrational or dysfunctional. Instead the focus is to discover the person’s ‘database’ or evidence for their beliefs and assumptions. Questions to expand the perspectives can be used later to generate alternative meanings.
Collaborative empiricism is a central principle in CBT. This involves collaborative understanding of the patient’s beliefs and then systematically testing their subjective hypothesis through questions and experiments. The process is transparent and open. Assumptions would be seen as hypothesis to be tested, rather than an established fact. By working jointly as an investigative team, the therapist and patient tests the accuracy and usefulness of the thoughts, beliefs and assumptions. If the thoughts were not accurate or useful, the therapist is encouraged to revise them, using more valid facts.
Cognitive behavioural integration: cognitive therapists combine cognitive and behavioural interventions in therapy (Table 7.3). They add a cognitive perspective to behavioural interventions such as exposure. For example, in behavioural experiment (BE), the patient’s specific prediction about an exposure task is written down in advance (e.g. People will laugh at me if I go out). The patient is encouraged to test the prediction through an appropriate experiment. Once completed, the actual outcome would be compared with the original prediction. In most cases, the patient’s predictions would be different to the actual outcome. The patient would be invited to think about the difference between prediction and outcome. Thus in CT, the exposure task (anxiety about being with people) was transformed to an opportunity to test underlying beliefs.
Table 7.3 Behavioural interventions
Related posts:
Chapter 3 – Referral for Psychodynamic Psychotherapy: Processes and Considerations
Chapter 10 – Cognitive Analytic Therapy (CAT):
Chapter 11 – Group Analytic Psychotherapy and the Group Analytic Model: A Clinician’s Guide
Chapter 16 – Complex Post-traumatic Stress Disorder
Chapter 20 – Forensic Psychotherapy
Chapter 25 – Therapeutic Communities
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