Practicing Positive CBT

From Reducing Distress to Building Success

Fredrike Bannink

• Publisher: Wiley-Blackwell
• Year: 2012
• ISBN:
  9781118328972
• Edition: 1
• Topic: Psychology
• Subtopic: Cognitive Behavioral Therapy (CBT)
• Index: Psychology

Practicing Positive CBT: From Reducing Distress to Building Success reveals a new therapeutic approach that combines traditional CBT with Positive Psychology and Solution-Focused Brief Therapy.

By shifting the focus of therapy from what is wrong with clients to what it right with them and from what is not working to what is, Positive CBT creates a more optimistic process that empowers clients and therapists to flourish.

• Increases client motivation and collaboration; allows therapeutic outcomes to be achieved in shorter timeframes and in a more cost-effective way
• Covers theory and applications, and provides a wide range of stories, exercises and case studies
• The author has a uniquely broad knowledge and experience as a therapist and trainer of CBT, PP, and SFBT

Part I

Theory

1

What is CBT?

Being happy doesn’t mean that everything is perfect. It means that you’ve decided to look beyond the imperfections

Friedrich Nietzsche

Introduction

Cognitive behavioral therapy (CBT) is a psychotherapeutic approach, a talking therapy. The roots of CBT can be traced to the development of behavior therapy in the early 1920s, the development of cognitive therapy in the 1960s, and the subsequent merging of the two. It was during the period 1950 to 1970 that behavioral therapy became widely utilized, with researchers in the United States, the United Kingdom, and South Africa who were inspired by the behaviorist learning theory of Pavlov, Watson, and Hull.

Pioneered by Ellis and Beck, cognitive therapy assumes that maladaptive behaviors and disturbed mood or emotions are the result of inappropriate or irrational thinking patterns, called automatic thoughts. Instead of reacting to the reality of a situation, an individual reacts to his or her own distorted viewpoint of the situation. For example, a person may conclude that he is worthless simply because he failed an exam or did not get a date. Cognitive therapists attempt to make their clients aware of these distorted thinking patterns, or cognitive distortions, and change them (a process termed cognitive restructuring).

Behavioral therapy, or behavior modification, trains clients to replace undesirable behaviors with healthier behavioral patterns. Unlike psychodynamic therapies, it does not focus on uncovering or understanding the unconscious motivations that may be behind the maladaptive behavior.

CBT integrates the cognitive restructuring approach of cognitive therapy with the behavioral modification techniques of behavioral therapy. The goal of CBT is to help clients bring about desired changes in their lives. The objectives of CBT are to identify irrational or maladaptive thoughts, assumptions, and beliefs that are related to debilitating negative emotions and to identify how they are dysfunctional, inaccurate, or not helpful. This is done in an effort to reject the distorted cognitions and to replace them with more realistic and self-helping alternatives. The client may also have certain fundamental core beliefs, called schemas, which are flawed and require modification. For example, a client suffering from depression may avoid social contact with others and suffer emotional distress because of his isolation. When questioned why, he reveals to his therapist that he is afraid of rejection, of what others may do or say to him. Upon further exploration with his therapist, they discover that his real fear is not rejection but the belief that he is uninteresting and unlovable. His therapist then tests the reality of that assertion by having the client name friends and family who love him and enjoy his company. By showing the client that others value him, the therapist both exposes the irrationality of the client’s belief and provides him with a new model of thought to change his old behavior pattern. In this case, the client learns to think “I am an interesting and lovable person; therefore I should not have difficulty making new friends in social situations.” If enough irrational cognitions are changed, he may experience considerable relief from his depression.

Initial treatment sessions are typically spent explaining the basic tenets of CBT to the client and establishing a positive working relationship. CBT is a collaborative, action-oriented therapy effort. As such, it empowers the client by giving him an active role in the therapy process and discourages any over­dependence on the therapist. Treatment is relatively short, usually lasting no longer than 16 weeks.

Both positive alliance – a positive bond between therapist and client – and empirically supported treatment methods enhance therapy outcome. There is evidence that positive therapy alliance potentiates the effectiveness of empirically supported methods (Raue and Goldfried, 1994) and there is also evidence that using effective methods leads to a more positive alliance (DeRubeis, Brotman, and Gibbons, 2005).

CBT Techniques

Different techniques may be employed in CBT to help clients uncover and examine their thoughts and change their behaviors. They include:

• Clients are asked to keep a diary recounting their thoughts, feelings, and actions when specific situations arise. The journal helps to make them aware of their maladaptive thoughts and to show their consequences on behavior. In later stages of therapy, it may serve to demonstrate and reinforce positive behaviors.
• Cognitive rehearsal. The clients imagine a difficult situation and the therapist guides them through the step-by-step process of facing and successfully dealing with it. The clients then work on rehearsing these steps mentally. When the situation arises in real life, the clients will draw on their rehearsed behavior to address it.
• Clients are asked to test the validity of the automatic thoughts and schemas they encounter. The therapist may ask the clients to defend or produce evidence that a schema is true. If clients are unable to meet the challenge, the faulty nature of the schema is exposed.
• Modeling. The therapist and client engage in role-playing exercises in which the therapist acts out appropriate behaviors or responses to situations.
• Conditioning. The therapist uses reinforcement to encourage a particular behavior. For example, a child gets a gold star every time he stays focused on tasks and accomplishes certain daily chores. The star reinforces and increases the desired behavior by identifying it with something positive. Reinforcement can also be used to extinguish unwanted behaviors by imposing negative consequences.
• Systematic desensitization. Clients imagine a situation they fear, while the therapist employs techniques to help the client relax, helping the person cope with his fear reaction and eventually eliminate the anxiety altogether. The imagery of the anxiety-producing situations gets progressively more intense until the therapist and client approach the anxiety-causing situation in real-life (graded exposure). Exposure may be increased to the point of flooding, providing maximum exposure to the real situation. By repeatedly pairing a desired response (relaxation) with a fear-producing situation (open, public spaces) the client becomes desensitized to the old response of fear and learns to react with feelings of relaxation.
• Relaxation, mindfulness, and distraction techniques are also commonly included.
• Cognitive behavioral therapy is often also used in conjunction with mood stabilizing medications to treat conditions like depression and bipolar disorder.
• Homework assignments. Cognitive-behavioral therapists frequently request that their clients complete homework assignments between therapy sessions. These may consist of real-life behavioral experiments where patients are encouraged to try out new responses to situations discussed in therapy sessions.

Empirical Evidence

There is empirical evidence that CBT is effective for the treatment of a variety of problems, including mood, anxiety, personality, eating, substance abuse, and psychotic disorders. Treatment is often manualized, with specific technique-driven brief, direct, and time-limited treatments for specific psychological disorders.

CBT is used in individual therapy as well as group settings, and the techniques are often adapted for self-help applications. Some clinicians and researchers are more cognitive oriented (e.g., cognitive restructuring), while others are more behaviorally oriented (e.g., in vivo exposure therapy). Other interventions combine both (e.g., imaginal exposure therapy). Many CBT treatment programs for specific disorders have been evaluated for efficacy; the health-care trend of evidence-based treatment, where specific treatments for symptom-based diagnoses are recommended, has favored CBT over other approaches such as psychodynamic treatments.

CBT may be seen as a class of treatments, which have the same features in common and also differ in important respects. It is problem-focused and structured towards the client; it requires honesty and openness between the client and therapist, as the therapist – being the expert – develops strategies for managing problems and guiding the client to a better life.

2

What is Positive CBT?

Treatment is not just fixing what is wrong; it is also building what is right

Martin Seligman

Introduction

Suppose you are hungry and decide to eat in a restaurant. After having waited for some time, you are invited to take a seat and the manager introduces himself. He asks you questions regarding your hunger: “How hungry are you? For how long have you been preoccupied with this feeling? Were you hungry in the past? What role did hunger play at home with your family or with other relatives? What disadvantages and possibly advantages does hunger have for you?” After this, having become even hungrier, you ask if you can now eat. But in addition the manager wants you to complete some questionnaires about hunger (and perhaps about other issues that the manager finds important). Once everything is finished, a meal is served to you that you did not order, but that the manager claims is good for you and has helped other hungry people. What are the chances of you leaving the restaurant feeling satisfied?

According to the traditional cause-effect model (also called the “medical model” or the “problem-focused model”), one must first find out exactly what the matter is in order to assert a correct diagnosis before a remedy can be provided. In our western thinking, the cause-effect model is the pre-eminent model to make the world understandable. The model is useful if one is dealing with relatively straightforward problems that can, in actual fact, be reduced to simple and unambiguous causes, as is the case with medical or mechanical problems. When you have a toothache, the first question you ask is: what is wrong with my teeth? When your vacuum cleaner breaks down, the first question you ask is: what is wrong with my vacuum cleaner? The medical model consists of: diagnosis + prescribed treatment = symptom reduction. As far as psychotherapy is concerned, however, this model has a major disadvantage, that is, that it is heavily problem-focused. If the problem and its possible causes are studied in depth, a vicious circle may develop with ever-growing problems. The atmosphere becomes laden with problems, which poses the risk that solutions recede ever further from view and also that the hope of improvement dwindles. In this vein psychology became a victimology and psychologists and psychiatrists became pathologizers. Exploring or analyzing the factors that cause or perpetuate a problem does not automatically result in an improvement of the problem. Einstein (1954) stated that we cannot solve problems by using the same kind of thinking we used when we created them. Duncan (2010) also states that psychotherapy is not a medical endeavor, it is first and foremost a relational one. Yet, the medical model is the predominant description of what we do. “My account of psychotherapy lies outside of the language of diagnosis, prescriptive treatment, and cure and seeks to reflect the interpersonal nature of the work, as well as the consumer’s perspective of therapeutic process, the benefit and fit of the services.” (p. 184)

The British Psychological Society in their DSM-5 response (2011) state that they are concerned that clients and the general public are negatively affected by the continued and continuous medicalization of their natural and normal responses to their experiences – responses which undoubtedly have distressing consequences which demand helping responses but which do not reflect illnesses so much as normal individual variation.

Furthermore, research shows that among professionals using the problem-solving model there is a high percentage of stress, depression, suicide, burnout, and secondary traumatization. I shall explore these shortcomings further in the next paragraph.

Shortcomings of the Problem-Solving Paradigm

The problem-solving paradigm has become very popular in business, government, and in coaching, psychotherapy, and conflict management. In traditional forms of psychotherapy – and also in CBT – the focus is on pathology. The diagnosis of the problem is the first step. The next step is finding the causes of the problem, using the cause-effect model (the so-called “medical model” or “mechanical model”) as previously mentioned.

This is a very common way: something has gone wrong and we have to put it right. In medicine and psychotherapy problems are called a “deviation” from the normal: health is normal, sickness is a deviation and has to...