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Cognitive Behavioural Therapy – A Viewpoint

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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 was 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, iv vitamin therapy long island 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 die?

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 situation. 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”.

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