Cognitive Behavior Therapy

Core Principles for Practice

William T. O'Donohue, Jane E. Fisher, William T. O'Donohue, Jane E. Fisher

• Publisher: Wiley
• Year: 2012
• ISBN:
  9781118228876
• Edition: 1
• Topic: Psicologia
• Subtopic: Terapia cognitivo-comportamentale

Learn and apply the 14 core principles of cognitive behavior therapy

In this invaluable guide, clinicians will find—identified and summarized by leading researchers and clinicians—fourteen core principles that subsume the more than 400 cognitive behavioral therapy (CBT) treatment protocols currently in use, so they may apply them to their everyday practice. This unique contribution to the field provides practitioners with a balance of history, theory, and evidence-based applications.

Edited by renowned experts in the field, Cognitive Behavior Therapy explores the core principles behind all CBT protocols including:

• Clinical functional analysis
• Skills training
• Exposure
• Relaxation
• Cognitive restructuring
• Problem solving
• Self-regulation

A straightforward introduction to CBT principles with guidance for all mental health professionals seeking to improve the lives of clients spanning a range of psychological problems, Cognitive Behavior Therapy is designed for both new and experienced clinicians alike who want to deepen and broaden their understanding of CBT principles.

Chapter 1

The Core Principles of Cognitive Behavior Therapy

William T. O'Donohue
Jane E. Fisher

Cognitive behavior therapy (CBT) is an important therapeutic paradigm as it has been shown repeatedly to be an efficacious and effective intervention for a wide variety of psychological problems (Chambless & Ollendick, 2001). In fact, it might be argued in an important technical sense that it is the only valid therapeutic paradigm—as the honorific paradigm is not a synonym for theory or framework. Rather, in its canonical sense as originated in Kuhn (1996), a paradigm is viewed as emerging from preparadigmatic pursuits when the program solves a problem or problems. Thus, to deserve the descriptor paradigm, the approach has to have a demonstrated problem-solving ability. CBT has shown to be effective for a wide variety of psychological problems while other therapeutic theories simply have not (Chambless & Ollendick, 2001; Fisher & O'Donohue, 2006). In this important sense, CBT may be said to be the only or at least the foremost paradigm in psychotherapy.

For example, in the well-known Chambless report, the techniques of cognitive behavior therapy are nearly exclusively those cited as probably supported or definitely supported. Moreover, the range of effectiveness of these CBT techniques is also quite impressive: enuresis, depression, skill building in the developmentally delayed, and a number of anxiety problems as well as a few dozen other problems (see Fisher & O'Donohue, 2006). It is not a “one problem therapy” as arguably some other interventions are, for example, eye movement desensitization and reprocessing (EMDR) for posttraumatic stress disorder (PTSD). The extension of these core principles has several important practical advantages that are described in more detail further on.

CBT has other significant advantages. It is often quicker (although there are some notable exceptions to this such as the behavior analytic treatment of autism; see Lovass, 1987). CBT often involves a dozen or a few dozen hourly sessions when it is instantiated in individual therapy—which admittedly is still a significant time commitment, but much shorter than traditional psychoanalytic therapy and much shorter than open-ended supportive psychotherapy, which often has no clear terminus. Also, cognitive therapy can be cheaper, as time is the major driver of cost in most therapies. Perversely, in current practice, customers do not tend to have the information that is needed to purchase effectiveness and quality and thus an hour of CBT can cost the same as an hour of rebirthing or sand tray therapy. Managed care has attempted to curb this lack of differentiation in consumer decision making but largely has not been all that successful. However, healthcare reform is oriented toward increasing the value of healthcare purchases and we believe the demonstrated effectiveness will increasingly be a market differentiator (Cummings & O'Donohue, 2011).

Furthermore, cognitive therapy is often conducive to manualization and it can thus be scaled. Some therapies might depend on difficult-to-define constructs that might be unique to the personality of the founder of the therapy school and thus not easily taught and scaled. For example, Fritz Perls's (1973) Gestalt therapy, with its emphasis on theatrics, confrontation, vague constructs such as authenticity, and in-the-moment interpersonal dynamics might be much less readily taught and disseminated. Scalability is vitally important given the prevalence of the problems psychotherapy attempts to attenuate: The issue is not whether one or a few therapists can master the techniques but whether thousands can.

A significant problem arises, however, with the notion of manualized therapy. It should be understood that the problem attempted to be solved with a treatment manual is fidelity, which is related to generalizability (Haynes, Smith, & Hunsley, 2011). How can the therapy be faithfully executed with other therapists, in other settings, with other clients? With over 600 Diagnostic and Statistical Manual of Mental Disorders-IV-Text Revision (DSM-IV-TR) (American Psychiatric Association, 2000) diagnoses, is there to be a manual for each of these and thus a competent therapist must master dozens or even hundreds of these treatment manuals? The fidelity problem becomes more complex when one considers either comorbidity or any other second order variable (for example, therapist experience, intelligence, and clinical judgment). The number of permutations clearly becomes unmanageable. Would there be a manual for an individual with major depressive episode that also is suffering from comorbid panic disorder? Would there need to be still another manual for an individual with these two problems who is also Hispanic? When one crosses 600 diagnoses with comorbidity with another set of variables such as the therapist variables mentioned earlier, the combinatory number is staggering and practically unfeasible (for example, 600 × 600 × 8). One sees that one treatment manual for each category of problem as delineated by these kinds of parameters clearly produces an unmanageable number of manuals.

Moreover, one still needs to understand the core of the treatment manual. A treatment manual for PTSD may contain many particular requirements and subgoals, but some of these are much more critical than others. All requirements in a manual are not of equivalent importance. For example, in a therapy manual for PTSD clearly instantiating exposure principles is important, and how the therapist goes over homework in session two, less important (Zalta & Foa, this volume, Chapter 4). This kind of consideration suggests that understanding the core principles of behavior therapy can be useful in faithfully and effectively delivering evidence-based treatment.

In addition, manuals cannot anticipate the idiosyncratic nature of many actual clinical cases. An understanding of the core principles embodied in the manual can be helpful to successfully adapting a manual to an idiosyncratic situation. For example, the range of trauma can be unique; for example, viewing one's brother dying from a untreated rattlesnake bite would be an occurrence that could be part of therapy but is not of a frequency that will ever be described in any detail in a treatment manual for PTSD. However, when one understands the core principle of exposure one is more likely to be able to effectively adapt a CBT PTSD treatment to this case.

Thus, one advantage of thinking in terms of principles is that it allows a more parsimonious but at the same time a deeper understanding of the mechanisms of change underlying treatment. This is of importance because although there are currently 600 individual diagnoses in the DSM-IV-TR (American Psychiatric Association, 2000) the trend across additions of the DSM is for new additions to include many additional diagnoses. Our field would be very complex indeed if each diagnosis had its own treatment manual with unique change principles underlying each diagnoses. Instead and quite fortunately it appears to be the case that a set of core principles underlies effective cognitive behavior therapy. For example, exposure therapy and modifying beliefs seems to be key to a variety of anxiety disorders (see Zalta & Foa, this volume, Chapter 4). Skills acquisition and contingency management seems to be the keys underlying treatments for the developmentally disabled and autism spectrum disorders (see chapters by Twohig & Dehlin, this volume, Chapter 3; Rummel et al., this volume, Chapter 2). Thus, understanding some central core principles can povide a more coherent and parsimonious way of understanding the treatment of a broader range of individual disorders.

Second, these core principles allow a deeper understanding of change processes. Treatment manuals tend, by their nature, to have a fair amount of detail. Each detail specifying some therapeutic requirement does not have equal weight in producing beneficial outcomes. Understanding the principles that are being instantiated in the therapy manual can help the clinician to better understand the key components of treatment. Also, if the therapy needs modifications to meet the individual needs of the patient (for example, the patient needs more compressed treatment because they don't have time for the full 18 sessions that the manual specifies) an understanding of the core principles underlying the manual can help the clinician to accomplish these modifications in a faithful and effective manner.

A corollary of this is that manuals should be explicit on what principles they are attempting to instantiate. These ought to state something along the lines of “in the next two sessions two principles are being implemented: (1) identifying and modifying irrational beliefs and (2) apply behavioral activation principles so as to increase the patient's contact with positive events.” This will allow the clinician a better understanding of the underlying importance of some of the goals of the therapy manual.

This can also mean that more process research is needed to better understand the actual mechanisms of change in therapies that have been identified as effective. The Chambless report mentioned earlier sometimes does this but mostly fails to. This is partly due to a notable particularity of trends in CBT research. In the early years, especially in the behavior analytic tradition, process variables were identified and directly manipulated to see their impact on outcome variables (O'Donohue & Houts, 1985). Titles of papers were more along the lines of “The effect of contingency management on increasing homework.” The principle—contingency management in the outcome research—was clearly specified. Increasingly, therapeutic packages or therapies with general titles are tested and it is unclear what the active ingredients of change are. Thus, if the title is something along the lines of “The effect of ACT on depression”; or “DBT reduces parasuicidal behavior,” it is much less clear in these multicomponent packages what principle or principles are being employed. Clearly we need more process research and dismantling research to better identify key elements of change. Otherwise, the relative importance of the components of a manual are not clear.

Therapy Is Not an Art

An implication of the identification of key principles underlying effective behavior change techniques is that therapy is not essentially an art. This is good news, because there are very few good artists and a lot of hacks. However, when something is a technical enterprise—such as civil engineering—there can be a high degree of general competence across practitioners. Therapy is at least in large part a technical enterprise that involves the skillful application of the active ingredients of change. It is thus partly a technology. Certainly this is not to say that therapy is mechanistic or algorithmic. However, a key question each therapist can ask herself in each session is: “What principles of change am I implementing in the treatment design?” If the answer is none, the therapist is likely to be wasting the client's valuable time and money.

It is certainly the case that these principles can be somewhat artfully instantiated. It is important to note, however, that these principles also provide constraints. It is not acceptable art to do sand tray therapy, or rebirthing, or psychoanalysis, or supportive psychotherapy, as there are no identified causal mechanisms that can bring about change—particularly when compared to the alternatives discussed in this book. That is, if one is doing, say, nondirective therapy with someone who has panic attacks, then this can be legitimately criticized through this observation, “Exposure therapy and cognitive restructuring have been shown to be effective for this problem. The techniques you are implementing have not been. Why are you harming your patient by failing to provide them with a therapy based on principles that have empirical support?” This implies there are right answers in therapy; it is not a free-form art, though, but rather at least partly a technical problem, that is, what regularities have been shown to bring about the ends sought and how do I as therapist instantiate these regularities in this case? These principles need to play a large role in case formulation and treatment planning.

We believe that the principles outlined in this book bring accountability to therapist behavior and treatment planning. Therapists cannot simply implement a therapy that has caught their fancy but rather must design and implement therapies that are based on principles that have been supported as effective. This also implies that those that only rely on nonspecifics when designing or implementing therapy are doing so with the proverbial one hand tied behind their backs. Nonspecifics are clearly important. We believe,...