“A Little kindness and gentleness towards yourself is a wiser and more skilful response to feeling threatened than any amount of analytical problem solving” (Williams et al 2007, p. 217).

Cognitive Behaviour Therapy from Basics to Recent Developments

Introduction

At a recent professional training seminar on Mindfulness, Based Stress Reduction, Saki satorelli, (2009) one of the main innovators, with Jon Kabat Zinn, on the introduction of mindfulness approaches into western medicine said “there is nothing wrong with thoughts, but some times they just might point us in the wrong direction”. This statement indicates the prime position of thoughts or cognitions in cognitive therapy, and hints at two possible approaches as to how we deal with the cognitive process. In second generation modalities, the negative or unhelpful contents of the mind are the target of the change process. However more recent third generation approaches incorporate a mindfulness focus on our relationship to the content, as Stephen Hayes proposes“a conscious posture of openness and acceptance towards psychological events, even if they are formally negative irrational or even psychotic…can mean that a negative thought mindfully observed will not necessarily have a negative function” (Hayes, 2004 p.9) However before looking at second and third generation approaches, it is useful to briefly examine the first generation in this lineage of therapies, behaviourism.

First Generation: Behaviourism.

Behavioural approaches to depression focus on threat and safety seeking behaviours.While other schools such as psychoanalysis look at depression as resulting from inner conflicts, that are often unconscious. “Behavioural theories focus on the outputs and behaviours of living systems and the contexts in which behaviours are emitted”. (Gilbert, 1992 p.63) Consequently behaviourism is more concerned with the way a person interacts with the world , rather than placing the source of depression in side the person “in terms of faulty cognitions” (Gilbert, 1992 p. 63) This approach had its origin in the 1950s work of B.F. skinner who “championed radical behaviourism, which places primary emphasis on the effects of environment on behaviour” ( Corey, 2005 p.227) It was a departure from psychoanalytical approaches, and focuses on how principles of learning, derived from the experimental laboratory can be applied clinically.It is based on theories of classical stimulus and response conditioning, and operant conditioning, which involve learning from the positive or negative consequences of behaviour. Regarding the behavioural approach to depression, Ferster (1973) proposes that a depressed client has a distorted, incomplete and misleading view of his environment. For this type of client there is

  • A limited world view which leads to the client being unable to see what behaviours are appropriate for reinstating adequate levels of reinforcement.
  • A lousy view of the world .Whereby the depressed client, may be aware of what behaviours are required, but fears the adverse consequence of such behaviour.
  • An unchanging view of the world. Whereby it is not so much a lack of perception, or a fear of aversive consequences, but a lack of skills, whereby the client’s behavioural repertoire is not sufficiently developed.

Gilbert (1992) offers that the key points of behaviourism are a focus on the functions of behaviour, which are individual to a person. He see the client’s distorted view of his environment leading to approach – avoidance conflicts and painful dilemmas that can increase stress , and make people feel as if they are in a fog. Therefore safety behaviours such as submissiveness and avoidanceare the client’s way of trying to regulate problematic emotions .Furthermore emotions and fear of emotions are common internal problems that need to be addressed in depression. Learning how to accept, tolerate, and work with emotions and reduce depression related behaviours is central to many types of behavioural approach.

One such behavioural approach – Behavioural activation Therapy – focuses less on peoples interpretation and thoughts, and instead focuses on understanding the function of depressive behaviours, and how to enact specific anti -depressant behaviours. The key is to help the client to learn how depression has altered their styles of behaviour, such as becoming more limited or avoidant. The view is that our feelings and thoughts are heavily influenced by our behaviours. Accordingly the client is challenged into giving up their safety and ineffective defence behaviours. A main principle is that what a person puts into their lives can act as rewards and reinforcers. (Gilbert, 1992) Subsequently Cognitive Therapy did put the B back into the therapy that became Cognitive Behaviour Therapy, (CBT) and it incorporates many of theses behavioural activation strategies.

Second Generation: CBT. And Schema Therapy

Cognitive behaviour therapy retained the empirical approach of behaviourism, which Kuyen et al (2009, p.4) defined as an approach “in which hypotheses are continually developedBased on client experience, theory and research. These hypotheses are tested and then revised based on observations and client feed back.” Developed by Aron T. Beck in the 1960’s “as a result of his research on depression” (Corey, 2005 p. 283) CBT theory is based on the idea that instead of reacting to the reality of a situation a person can sometimes react in an ineffective and self defeating manner, to his own distorted viewpoint or cognitions, that are triggered by inappropriate or irrational thinking patterns. (Paula Ford – Martin, 2001) The client’s core beliefs- usually developed from experiences in early childhood or adolescence, - such as “I am a worthless person” become an established Schema “that form the basis for the regularity of interpretations of a particular set of circumstances” (Stanley, 2009) In the case of depression Beck sees that the client’s negative distorted views, are connected to what the client believes are a sense of loss to his personal domain. Furthermore beck observed, that the content of the clients negative automatic thoughts “tended to be peculiar not only to the individual patient but to other patients with the same diagnosis” (Beck, 1976 p. 105)

Therefore beck notes that “The depressed patient shows specific distortions. He has a negative view of the world, a negative concept of himself, and a negative appraisal of his future: the negative triad.” (Beck, 1976 p.106) At the core of CBT is the dynamic interaction, between the clients Thoughts, emotions, behaviour, physical reactions, and the client’s environment, as can be seen in Figure 1.below

Figure 1.Cognitive Behavioural Model

Source Mari Keenleyside (2007)

As stated by Greenberger and Padesky (1995, p.4) “the.. areas are interconnected. The connecting lines show that each different aspect of a person’s life influences all other areas.”

This model helps client and therapist, to collaborate in understanding what is going on for that client. It is often the first stage, in the educative process for the client, and the beginning, of the client and therapist developing a rudimentary case conceptualisation.The case formulation is a hypothesis of what is going on for the client, worked out in collaboration between counsellor and client. The case formulation approach “Conceptualises psychological problems as occurring at two levels: the overt difficulties and the underlying psychological mechanisms”.Jacqueline B Persons ( 1989, p.1) So that real life problems such as low mood and depression are tagged to the underlying psychological mechanisms, which are often expressed in terms of the afore mentioned irrational beliefs about the self, the world and the future. A CBT example of a Case formulation of Depression is shown below in figure 2.

Figure 2 C.B.T. Case Formulation of Depression :Source Eoin Stephens (2007) Amalgamation of charts mine.

While the case formulation helps to elaborate what is going on for the client regarding their automatic thoughts, assumptions, and core beliefs, it does not ignore behaviour. Moreover it guides the counsellor in the most appropriate initial intervention. Kuyen et al state (2009, p. 26) that conceptualization “ is original and unique to the client and reveals pathways to lasting change” The intervention pathway can initially be a behavioural intervention. In my experience this tends to be he case where a client presents with a high degree of lethargy, and avoidance behaviour. In developing the case formulation, an assessment instrument, such as the Beck depression inventory,together with the use of Socratic dialogue, elicits from the client what Persons (1989) identifies as three types of problematic cognitions:

  1. Derivatives of the clients underlying irrational beliefs, which are automatic thoughts that also tend to be irrational.
  2. Maladaptive thoughts, which seem accurate and functional but focusing on them causes negative moods, impairs behaviour, and reinforces irrational beliefs.
  3. distorted thoughts involve an unrealistic view of reality or involve illogical reasoning.

An empirical CBT intervention for depression, incorporating Persons ( 1989) case formulation approach, and Padesky and Greenberger client manual (1995) could be as follows:

  • Establish therapeutic alliance
  • Assessment of clients presenting issues, relating these to the CBT model. Assessment may also include use of formal assessment instruments such as the Beck depression inventory.
  • Initial Case formulation in collaboration with client using Socratic dialogue.
  • Using Case formulation to identify underlying psychological mechanisms, and best intervention.
  • Behavioural Interventions, which can include,activity scheduling.
  • Cognitive interventions –which are at the core of CBT- these involve teaching the clients new skills, such as using a thought record to capture automatic negative thoughts that are related to depressed moods. Teaching the client the skill to challenge these negative automatic thoughts, by examining the evidence for, and against these thoughts. This leads to the client gaining new skills which includes reframing the negative thoughts to more reasonable and realistic alternative thoughts. This has a positive impact on the clients low mood
  • Measuring outcome by rescoring the intensity of the client’s depressive moods to, establish validity of interventions.
  • Design and implementation of experiments with client to test new beliefs.
  • Preparing client for leaving counselling and maintaining newly learnt skills

From this initial work with clients, it may become apparent that some progress has been made reframing the client’s negative automatic thoughts, and alleviating the client’s depressed mood. However Beck (1989, p. 181 ) proposes that “to understand more fully why people behave as they do, we have to look deep beneath their actions, beyond their automatic thoughts, and ferret out their basic beliefs.” Core beliefs or schema are defined by Gilbert (2007, p.212) as “basic organising systems for knowledge about the self and others. These are built up through life as the result of interpersonal experiences”.So another therapy in this second generationis Schema Therapy, which was founded by Jeffrey E.Young.in 1990. Described as an integrative approach for longer term disorders, such as personality disorder which are often associated with depression, and treatment- resistant clients (Young et al.2003) It blends aspects of CBT, Attachment, Gestalt, Objects relations, constructivist, and Psychoanalytic schools “into a rich unifying treatment mode”. (Young et al. 2003 p.1). This model sees clients as having emotional needs, such as,(Stanley 2009)

1.Secure attachment to others. (includes safety, stability, Nurturance, and acceptance)

2. Autonomy, competence and sense of identity .

3. Freedom to express valid needs and emotions

4. Spontaneity and play

5. Realistic limits and self control

Young et al (2003, p. 10) states,

“ a psychological healthy individual is one who can adaptively meet these core emotional needs…..the goal of schema therapy is to help patients find adaptive ways to meet their core emotional needs”

However early childhood experiences and the child’s emotional temperament can interact to form maladaptive schemas, which Young et al ( 2003, pp.13-21) group into five categories of unmet emotional need, termed domains, that detail as follows:

  1. Disconnection and Rejection: Clients with schemas in this domain are unable to form secure, satisfying attachments to others. They believe their needs for stability, safety, nurturance, love, and belonging will not be met.
  2. Impaired autonomy and performance: The ability to separate from ones family and to function independently, comparable to people of one’s age .Clients with Schemas in this domain, have expectations about themselves and the world that interferes with their ability to differentiate themselves, from parent figures and function independently.
  3. Impaired Limits: Clients with schemas in this domain have not developed adequate internal limits in regard to reciprocity or self discipline.They may have difficulty respecting the rights of others, cooperating, keeping commitments, or meeting long term goals.
  4. Other Directedness: Client in this domain place an excessive emphasis on meeting the needs of others, rather than their own needs. They do this in order to gain approval, maintain emotional connection, or avoid retaliation.
  5. Over vigilance and Inhibition: clients in this domain suppress their spontaneous feelings and impulses. They often strive to meet rigid internalized rules about their own performance at the expense of happiness, self-expression, relaxation, close relationships, or good health.

So in the assessment phase clients are helped to identify their schemas, to understand their origins, and the internal and external behaviours that perpetuate them. “Patient’s learn to recognise their maladaptive coping styles(surrender, avoidance, and overcompensation) and to see how their coping responses serve to perpetuate their schemas.”(Young et al 2003 p.44) Assessment has many aspects including life history, self monitoring, and schema questionnaire, which helps identify how relevant the various schemas are to a client’s life. But Gilbert cautions (2007,p.213) “they should not be used to imply there is some negative schema sitting inside an individual…..schema are about the way in which emotions and thoughts are organised and patterned around certain themes”. The assessment phase concludes with a schema focused case conceptualization. The Change phase includes: Stanley(2009)

  • Cognitive techniqueswhere the schema driven cognitive distortions are challenged
  • Interpersonal techniques which highlight the client’s interactions with other people so that the role of the schemas can be exposed.
  • Behavioural techniques, where the therapist assists the client in changing long- term behaviour patterns.

Additionally Hayes et al (2003, p .110) propose experiential techniques“to trigger the emotions connected to early maladaptive schemas and to re-parent the patient in order to heal these emotions and partially meet the patient’s unmet childhood needs”

Subsequently CBT became the parent of a new child in this lineage of therapies. One influenced by eastern philosophy. Particularly the experiential approach of mindfulness.

Third Generation: Mindfulness based strategies, MBCT, and ACT.

Two third generation therapies Mindfulness Based Cognitive Therapy,(MBCT)and Acceptance and Commitment Therapy (ACT)incorporate the experiential approach of mindfulness.

“Mindfulnesstraining is central to MBCT; it is also features,in other interventions designated by Hayes as part of the third wave of behaviour therapies such as ACT”.(Segal et al 2004, p.55) Mindfulness is defined By John Kabat Zinn, (2008) as, paying attention in a particular way: on purpose, in the present moment, and non-judgementally. Mindfulness involves moving from a doing goal orientated existence, into a being mode. It allows us to be more in touch with our being, through a systematic process of self observation, moment by moment, by simply witnessing, what is happening for us in the present, without trying to change anything. Shapiro’s (2006) model of mindfulnesshelps to focus on the psychological mechanisms that underline mindfulness based interventions.She proposes three axioms that are not linear, but a dynamic cyclical process, where interwoven aspects occur simultaneously. So that mindfulness, is this moment to moment process that includes these three axioms, as shown in figure 3, below:

Figure 3.Shapiro’s three Axioms of Mindfulness

Therefore mindfulness involves the intention, of paying attention, to internal and external experience, with an attitude, that is non- striving, and non- judgemental, indeed an openhearted welcoming acceptance. Shapiro equates these three axioms, as the internal behaviours involved in mindfulness, which she proposes can lead to a shift for the individual, which she terms re-perceiving. Subsequently Segal et al, (2004, p. 47) questioned

  1. “What is the nature of cognitive vulnerability to relapse in formerly depressed patients ?
  1. “How does cognitive therapy reduce this vulnerability?

Questioning theprevailing view was that CBT achieved this, as a result of specific effects in reducing dysfunctional attitudes, Segal et al (2002 p. 38)state “this hypothesis received little empirical support”. Instead of changes in the content of depressive thinking, being the pathway to change, their own “more detailed theoretical analysis suggested an alternative possibility”(Segal et al 2004, p. 51) Theyproposed that CBT, also leads to changes in how patients relate to their negative thoughts and feelings, this shift in perspective, involves patients in viewing them as passing mental events, in the mind that are not necessarily valid. The Buddhist influence on this approach can be seen in the words of the 14th Century Tibetan master Longchenpa when he says “in the same way as at noon in the hot season there appears on a plain the water in a mirage, so also by the power of habituation to a belief in the mind as self the mistaken presence of the fictions (about the world) comes like a Mirage ” (1976, p. 72 )The Role of habitual negative thinking patterns in clients who relapse into depression was recognised by Teasdale et al (2002) However they identified that CBT also involves a processof de-centering or distancing. This they declared may be a long term benefit of CBT thatteaches clients to initiate this process when facing future stress. Based on this they developed the model shown below as the conceptual model underlying the development of MCBT.