Cognitive Behavioural Therapy – A Viewpoint

Background: Since the late 60s I've followed a progression of fashionable therapies and studied others back to the turn of the previous Century. I've seen little genuinely new. Mostly just repackaging under new authorship. Long before the term „CBT“ became popularised psychologists were making full use of it but they simply talked of an „eclectic cognitive restructuring approach“ or „behaviour modification techniques.“ Then there's the question of the effectiveness of one therapy compared to another. There seems to be no dearth of impressive looking research proving that each therapy is superior to each other! And note well: CBT is not really a single therapy or technique.

Katy Grazebrook & Anne Garland write: „Cognitive and behavioural psychotherapies are a range of therapies based on concepts and principles derived from psychological models of human emotion and behaviour. They include a wide range of treatment approaches for emotional disorders, along a continuum from structured individual psychotherapy to self-help material. Theoretical Perspective and Terminology Cognitive Behaviour Therapy (CBT) is one of the major orientations of psychotherapy (Roth & Fonagy, 2005) and represents a unique category of psychological intervention because it derives from cognitive and behavioural psychological models of human behaviour that include for instance, theories of normal and abnormal development, and theories of emotion and psychopathology.“

Wikipedia free dictionary: „Cognitive therapy or cognitive behavior therapy is a kind of psychotherapy used to treat depression, anxiety disorders, phobias, and other forms of mental disorder. It involves recognising unhelpful patterns of thinking and reacting, then modifying or replacing these with more realistic or helpful ones. Its practitioners hold that typically clinical depression is associated with (although not necessarily caused by) negatively biased thinking and irrational thoughts. Cognitive therapy is often used in conjunction with mood stabilizing medications to treat bipolar disorder. Its application in treating schizophrenia along with medication and family therapy is recognized by the NICE guidelines (see below) within the British NHS. According to the U.S.-based National Association of Cognitive-Behavioral Therapists: „There are several approaches to cognitive-behavioral therapy, including Rational Emotive Behavior Therapy, Rational Behavior Therapy, Rational Living Therapy, Cognitive Therapy, and Dialectic Behavior Therapy.“

The above „definitions“ have the practical advantage that they don't really definine CBT; they don't tell us where it starts and ends. For example, there are published on the net results of comparative studies comparing CBT with a number of other therapies. One of those other therapies is „modelling“ (I call it monkey-see-monkey do). But modelling would be considered by many therapists, certainly myself, to be ecompassed by CBT and not something to be compared with it. Modelling is how you learned your most vital skills, like driving a car and your most vital occupational skills. It's how your local brain surgeons, bakers, mechanics and airline pilots learned their skills and how the bird in your backyard learned to pluck a grub from under the tree bark. Modelling is so important that it could not be ignored by a therapist on the basis that it did not fit some purist definition of „CBT“. But „modelling“ is only one psychological phenomenon not encompassed by some definitions of CBT but which are too important to be ignored.

If I am right, and CBT as it is practiced is a mishmash of therapeutic approaches that have always been used in an eclectic approach to psychotherapy then one might wonder why there any need to invent the term CBT? Well, for a start it justified a book and I suspect it helped American psychologists sell psychotherapy to their relatively new „managed health care“ (insurance) system as being „evidence based therapy“. It leans heavily on the conditioned reflex idea and has a „no-nonsense-let's-get-‚em-back-to-work-at-minimal-cost“ ring to it. (never mind about how they feel!)

Cognitive-Behavioural Therapy (CBT) can be seen as a repackaging and franchising of a group of therapies dating from before the 60s, with some emphasis perhaps on Albert Ellis‘ („A guide to rational living,“ Harper, 61) „rational emotive therapy“ (RET) which shares many of the underlying tenets of Buddhism (without the Nirvana and reincarnation), and Donald Michaelbaum's ('70s) „self talk“ therapy – (see also „What to say when you talk to yourself“, Helmstetter, 1990) in which like Ellis‘ he holds that we create our own reality via the things we say to ourselves; and the various techniques of attention distraction and use of countervailing mental images as described under the name Neuro-linguistic programming, e.g. „Practical Magic“, Stephen Lankton, (META publications 1980) & other books by Bandler & Grinder.

Arguably, other related ideas of the era encompassed by CBT can include Maxwell Maltz's „Psycho Cybernetics“ (like a servo-mechanism, we automatically approach increasingly more accurate approximations of our persistent goals) and Tom Harris‘ „transactional analysis“ (TA) which is a simple, pragmatic and non-mystical explanation of psychodynamics. It encourages insight into self and stresses the importance of „adult“ rational responses. CBT is even consistent with some „existential“ approaches, e.g. of Auschwitz survivor psychiatrist Victor Frankl („Mans‘ search for meaning,“ 1970 & 80 Washington Squ Press) which can involve asking oneself what one would do with ones‘ life if one knew when one was going to ?

The „behaviour therapy“ or „behaviour modification“ aspect naturally makes use of the principles of classical and operant conditioning, i.e. associating one thing or behaviour with another – e.g. a reward, or an escape, i.e. the reinforcement. To be effective reinforcement requires motivation, a need or „drive state“. Thus a response to the first thing becomes modified, or a style of behaviour becomes „reinforced“ and therefore likely to reoccur in specific circumstances. Classical conditioning applies to the reinforcement of autonomic responses, and operant conditioning to reinforcing skeletal responses.

In practice, the „behaviour“ part of CBT often involves using Wolpe's progressive desensitisation method (or a variation) which was originally based on the notion (partly false) that anxiety cannot exist in the presence of skeletal relaxation. This method involves a yoga style of progressive relaxation together with graded visualisations of the threatening . The client gets accustomed to visualising a low grade example of a threatening situation while staying relaxed, and when this becomes easy, moving on to a slightly more threatening visualisation. When this method is combined, in the later stages with real world exposure to graded examples of the threatening situation (preferably at first in the supportive presence of the therapist) it becomes a powerful treatment for phobias.

What is CBT used for?: Just about everything! The main things: panic, anxiety, depression, phobias, traumatic and other stress disorders, obsessional behaviour and relationship problems.

The procedure. A. In collaboration with the client, define the problem. If the problem is intermittent look for triggering or precipitating factors Try to formulate concrete behaviourally observable goals for therapy.“How would your improved confidence actually show to others?“ How could your improvement be measured? How will you really know you are „better“?

Lead the client to expect a favourable outcome. This is using suggestion. Doctor's words on medical matters, even their frowns, grimaces and „hmm hmms“ have enormous suggestive power and can do both harm and good. Anxious patients are prone to misunderstand and put negative interpretations on what is said to them. Also they may hear only certain key words and fail to put them in the context of the other words which they might not „hear“ or understand – i.e. they are „looking for trouble“, jumping to the wrong conclusions or to use a term coined by Albert Ellis, „catastrophising“.

B. Of course CBT requires all the normal forms of good practice in counselling technique best described elsewhere.

C. According to the exigencies presented by the client's problem and lifestyle, make use of any one or combination of the following:

1. Simple measures like practising slow diaphramatic breathing during panic attacks, getting sufficient exercise and giving attention to good nutrition and adequate social contact. Mental (cognitive) rehearsal: (a) Ask the client to divide a desirable response into a number of steps or stages. (b) Have the client imagine actually performing each desirable step leading to the complete satisfactory response. (c) Set a homework assignment of actually experimenting and practicing in „real world“ some or all of the steps drawing upon the imaginary practice for confidence.

2. Client's journal: A diary can be divided into time slots, smaller than a day if necessary. Or the diary can focus on just the significant events. Some headings: (a)The time, (b)what happened, (c)how I actually behaved including what I said, and (d)what I felt. (e)What should have I done/will do next time? Over time the diary or journal can be a valuable learning tool and source of confidence and inspiration for mental rehearsal.

. Modelling: This is what I call „monkey see monkey do.“ In its purist form it involves learning by observing and receiving encouragement and useful feedback from someone who is expert in the desired behaviour. Practice and competence banishes anxiety. This is how all vital skills are learned, from surgery and aviation to panel beating. I once sent a timid youth out night-clubbing with another young who was expert at approaching strangers of the opposite sex, and totally devoid of social fear. Training videos can provide a useful and convenient form of modelling. For example there was a time when South Australia's Mental Health service's Cerema Clinic made use of videos modelling sexual behaviour for sex therapy. Videos on various topics can be helpful to corporate persons with anxieties related to their performances (e.g. speaking up at meetings, or speaking to high status persons – „executive phobia“.). Modelling can involve joining a special interest training group, e.g. Toastmasters or the Penguins as part of the homework.

4. Relaxation techniques. These can involve the techniques commonly used with hypnotherapy. The relaxation procedure itself follows closely the format of yoga relaxation. Once a pleasant state of relaxation or trance like state is achieved systematic desentisation can be attempted and so too methods such as encouraging clients to construct or their own mental place of refuge to which they can retreat any time they choose for mental refreshment – it can be simply a room or a castle or whatever pleases the client. A variation or addition to this technique can be the invention by the client of a fictitious guru or teacher. Some religious people are already using this technique in the form of a belief in guardian angels. But literal belief is not necessary.

4. Systematic desensitisation: E.g. for a spider phobia. The patient is guided through a relaxation routine similar or identical to yoga relation and perhaps then asked to visualise a tiny little spider down the end of a long hall, so far away it is hard to see it. When the patient can visualise this without rising tension (patient can indicate tension by raising index finger) the image is made slightly more threatening. With spider phobias I make use of a children's book with the artists‘ friendly stylised pretty spiders being held up at a distance, and moving up to a documentary book with clear photography, the book eventually being held on lap by the client and browsed. Finally the client keeps and feeds a spider in a jar at home at the bedside, brings it to sessions and in my presence opens the jar and releases the spider. I always try to introduce real-world practice. I have spent nearly 2 hours riding up and down an elevator in Adelaide's David Jones store in Rundle Mall with an elderly lady clinging to my shirt. We were getting strange looks from the store detectives! She was after about 2 hours, able to do it alone while I had coffee in a totally different store 100 metres away.

5. Self talk: Get the patients to identify what they are saying to themselves during episodes of say anxiety or depression and to document the precipitating stimuli. This where the journal or diary mentioned above can be useful. Then the patients are asked to write a better script, more uplifting or productive things to say to themselves during such times. This is where Albert Ellis‘ (mentioned above) ideas can be useful. He points out we make ourselves miserable by catastrophising, and by expecting too much of the world. It is not reasonable to expect to be liked by everyone. A failed dinner party is a trivial matter not genuinely „ghastly“, „horrible“, or „terrible“! We should do what we can to make a bad situation better, but worrying beyond that is wasted emotional energy.

Does everyone agree CBT is a good thing? No. Arthur Janov of „The primal scream“ fame (70s) saw these methods as a symptom of a useless, superficial „let's get ourselves together“ approach that ignored the inner realities, the neurological concomitants of neurosis. Simon Sobo, in his Psychiatric Times article (July, 2001), „On the banality of positive thinking“, sees CBT as a symptom of economic rationalism and the whole „cookie cutter“ one treatment fits all approach to both psychological diagnosis and treatment. Again he argues that the patient's realities get ignored. But one does not have to totally discard all the concepts of analytical therapies. Throwing the baby out with the bathwater would be a big mistake. For example it would be a massive mistake to dismiss the importance of symbolism just because symbolism is a feature of Freudian and Jungian psychology. We are symbol using animals. These very words are symbols. The psychology of symbolism is not alien to stimulus-response psychology because it is precisely via the processes of reinforcement that things and events acquire their symbolic value.

If you look at books on CBT you will see that it is recommended that patients keep a journal with many headings. A great many of patients suffer depression. Depression patients lack energy and are procrastinators so about 30-40% of them never get as far as even buying a little book to write in. Others don't bother because they are quick to see that the CBT procedures or „homework“ being recommended are irrelevant to their situation. For example some of my depression and panic patients are women who are trapped in a marriage with a husband they despise but at the same time are dependent on. There often seems to be a passive-aggressive lose-lose aspect to their behaviour as refusing to drive a car, or spending husband's entire pay packet or credit card limit on the „pokies“ in hotel gaming rooms, or getting arrested for shoplifting.

I'm inclined to agree with Sobo. CBT has been packaged and marketed in a way to make it agreeable to the USA's managed health care system – and of course to health insurance systems generally. So we therapists go on doing what we've always done but with attention to the required nomenclatures and of course we try to bring in some positive results at the stipulated price. The bottom line is that unless our patients/clients have access to substantial health insurance benefits then all we have is a cottage beer money industry, which has been the case in Australia until November 2006.

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