CBT Values and Ethics

David Kingdon, Nick Maguire, Dzintra Stalmeisters, Michael Townend

• Publisher: SAGE Publications Ltd
• Year: 2017
• Print ISBN: 9781446273012, 9781446273005
• eBook ISBN: 9781526421371
• Edition: 1
• Topic: Psychology
• Subtopic: Psychotherapy Counselling
• Index: Psychology

Reflecting the current legal, professional and cultural context of CBT practice this book provides therapists and counsellors with an understanding of both the values and ethics that accompany this approach.

Providing real examples and reflective questions to encourage trainees to think about their own practice, this book takes the time to explain the principles and source of clinical ethics before focusing on the specific requirements for CBT users, including:

• CBT techniques
• Responsibilities to your client
• Competence
• Evidence

It provides real examples and reflective questions to help you think about your own practice. This book will be your guide to CBT specific vales and ethics as you train and continue into practice.

 

 

1 General Principles of Values and Ethics

Learning outcomes

After reading this chapter and completing the activities at the end of it, you should be able to:

1. Be aware of the range of cognitive behavioural therapies that have developed.
2. Understand why an appreciation of general principles of ethics matters.
3. Know what types of ethical theories are relevant.
4. Realise the importance of human rights, ethical and legal frameworks.
5. Know the sources of value statements for mental health care that can help.
6. Clarify the specific principles that relate to psychological treatment.
7. Use the sources for ethics particularly relevant to CBT.

We are going to begin by providing a broad description of cognitive behavioural therapy and then describe some broad ethical principles relevant to using it.

Cognitive behaviour therapy

Since Freud developed theories of the ways in which one’s internal world may govern behaviours, a wide range of therapies have developed. Evidence to support the effectiveness of psychological therapies has followed – more for some than for others. This empirical approach formed part of the behavioural work of Thorndike (1905), Watson (1913) and later Skinner (1938, 1971), and was later operationalised as a formal psychological therapy by Wolpe (1968) and Marks (1987). Cognitive aspects of psychological therapies first appeared in Kelly’s (1955) personal construct theories and then Ellis’s rational emotive behaviour therapy (1962) and Beck’s cognitive behaviour therapy (1963). Behavioural theories have proved robust over a century of experimental investigation, with cognitive processing research being comparatively younger with 30 to 40 years of work.

There are, very broadly, three schools of psychological therapy based on distinct theories of pathology and change. Psychoanalytic and psychodynamic therapies were until perhaps the mid-1980s dominant in the field of talking therapies. However, a lack of empirical validation of theory and effectiveness, with a growing evidence base for both cognitive and behavioural therapies, led to a significant shift, culminating in the government-sponsored Improving Access to Psychological Therapies programme (IAPT) making CBT the main model. More recently, evidence has developed for related therapies, including brief interpersonal therapy (Klerman and Weissman, 1994) and mentalisation-based therapy (Bateman and Fonagy, 2012).

There are now around fifty or more interventions based on the expression of the relationship between thoughts, feelings and behaviours. The interventions make use of techniques which enable a number of change processes, particularly important among them is ‘metacognition’ (the ability to reflect on one’s own thoughts and internal world) and cognitive/behavioural habituation. Most of these therapies are based on theories that have received empirical attention to demonstrate their validity. These therapies fall into two basic groups, sometimes referred to as ‘second’ and ‘third wave’ cognitive therapies, the first wave being therapies based on behavioural principles. The different forms of CBT often have different theoretical foci, but overlap in significant ways. Below is a brief consideration of the main families of cognitive and behavioural therapies, which arguably have coherent theories and effectiveness evidence bases.

Families of cognitive and behavioural therapies

The most widely used approaches were developed by the ‘father’ of CBT, Aaron Beck, who first published a fully formulated treatment approach for anxiety and depression in 1979 (Beck et al., 1979). The theory proposes that the negative content of thoughts is important, originally expressed as thinking errors. It is these that lead to and maintain distress and maladaptive safety behaviours, which in turn maintain the thought system. Cognitive processing is acknowledged in terms of distortions, and it is theorised that problematic ways of thinking due to fundamental (core) beliefs and ‘rules for living’ formed in interaction with childhood experience then lead to ‘safety behaviours’ that enable the avoidance of distress. Therapeutic interventions involve identifying problematic ways of thinking in terms of content, and testing them and emotion intensity using behavioural experiments. It may be delivered in individual and group formats.

Schema-focused cognitive therapy (Young et al., 2003) was developed to treat the complex interpersonal issues inherent within personality disorder. Young et al. identified 18 fundamental ‘schema’ from patient records, i.e. clusters of beliefs about the self and others that drive perceptions and maladaptive behaviours. The theory posits different ‘modes’ of operating (behavioural repertoire subsets), to which people move, depending on contextual factors, and that there are three broad ways of attempting to cope with distress: schema avoidance, overcompensation and surrender.

Dialectical Behaviour Therapy (DBT; see Linehan, 1993) focuses on reducing maladaptive behaviours (particularly self-harming behaviours) and increasing functioning for people with complex trauma issues. The premise is that clients have not yet acquired certain skills, e.g. managing emotions, establishing and maintaining relationships (perhaps due to attachment disruption and/or inconsistent, punishing or neglectful parenting). Emotion dysregulation is a key issue and interventions develop skills to manage anger and anxiety. The biosocial model theorises that the set of symptoms termed ‘personality disorder’ stem from a combination of an early invalidating environment, together with a biological predisposition to high arousal. The therapeutic relationship is an intrinsic aspect of DBT treatment as a model of a healthy relationship and also to reinforce behaviours that are less harmful to the individual. ‘Mindfulness’ techniques are used to enable clients to notice the negative judgements that they make about themselves and others.

Acceptance and Commitment Therapy (AaCT; see Hayes et al., 1999) is based on an empirical theory, Relational Frame Theory (RFT), which associates language (internal dialogue) with distressing experience. The useful concept of ‘cognitive fusion’ is described, i.e. that our emotional experience becomes ‘fused’ with the words we use to describe it. Treatment makes use of techniques to enable the individual to accept difficult life events and defuse from troubling experience. This may be enabled by experiential ‘defusion’ from meaning of words and concepts. Articulation of an individual’s values is important, which may enable the individual to be clear about behaviours in which they engage that are in the service of those values.

Mindfulness-Based Cognitive Therapy (e.g. Segal et al., 2012) has an evidence base in treating recurrent and severe depression. The practice of mindfulness (purposefully paying attention to experience, including thoughts) has been found to be particularly useful in reducing the intensity of depression experienced, and the lengths and frequency of depressive episodes. The therapy makes use of theoretical findings, indicating that negative moods can increase the likelihood of negative images and thoughts, thereby exacerbating the depressed mood.

Values and ethics

So, that describes CBT. Now we will move on to discuss values and ethics. You may ask why you need to know about general principles of values and ethics? It is quite likely that in your day-to-day practice, these can all seem to be a bit distant and irrelevant. But, you may meet a problem that we have not covered or a combination of issues that seem to need apparently conflicting approaches. You may need to explain the reasons behind your chosen approach to a client or trainee. In these circumstances, you can sometimes find it very helpful to be able to speak from first principles – if you can remember them. We will keep it simple for that reason and, by the end of the chapter, we hope that you might even find it interesting – we have, and have learnt a lot in the process.

Two distinct types of rights are defined by philosophers: natural and legal rights. Natural rights are viewed as more basic ‘elemental’ and therefore not related to laws, culture or beliefs but fundamental and universal. Legal rights are those which come from specific legal systems derived from individual cultural norms and expectations and so can vary between countries. However, there are also legal rights which transcend national systems: the Universal Declaration of Human Rights is the most prominent of these. In Europe, the Council of Europe also has considerable influence. Each has enshrined natural rights into international law, with the highest priority being given to the right to life and to liberty. There are also specific provisions for people with mental health problems, e.g. in the Council of Europe Committee of Ministers Recommendation on Human Rights and Psychiatry (2004: 11; Kingdon, Jones and Lönnqvist, 2004).

There is a history to this: John Locke (1841) held life, liberty and property to be primary considerations in describing rights:

• Life: Everyone is entitled to live once they have been created.
• Liberty: Everyone is entitled to do anything they want to as long as it does not conflict with the first right. (You might also think that there is a trade-off with other people’s rights, and not just of their right to live, but we’ll come to that later.)
• Property (or ‘Estate’): Everyone is entitled to own all they create or gain through gift or trade, so long as it does not conflict with the first two rights.

However, property has been deemed in some frameworks to be subordinate to ‘pursuit of happiness’. In the 1776 United States Declaration of Independence, these rights were famously condensed to:

We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable Rights …

The signers of the Declaration of Independence deemed it a ‘self-evident truth’ that all men are ‘endowed by their Creator with certain unalienable rights’. ‘Unalienable’ means ‘incontrovertible’ – or, if that doesn’t help explain it, ‘absolute rights’. However, it may not matter because Rousseau (1920) believed that the existence of unalienable rights, whatever they are, is unnecessary for the existence of a constitution or a set of laws and rights. His idea was of a ‘social contract’, which is the most widely recognised alternative to unalienable rights. The social contract describes the agreement between members of a country to live within a shared system of laws and that rights and responsibilities are derived from a consensual, agreed, contract between the government and the people. Specific actions of government are the result of the decisions made by members acting in their joint collective capacity. Government is instituted to make laws that protect the three natural rights mentioned previously, i.e. to life, liberty and property. However, if a government does not properly protect these rights, the populous, the people, has the right to overthrow it.

Hutcheson, on this theme, also placed clear limits on the notion of unalienable rights, declaring that: ‘there can be no Right, or Limitation of Right, inconsistent with, or opposite to the greatest public Good’. He elaborated on this idea of unalienable rights in A System of Moral Philosophy (Hutcheson, 1755), based on the principle of the liberty of conscience. This had come about because of the Reformation of the Church which had bought to prominence the idea that there were further rights that were important and acting according to your conscience was one of these rights.

This is getting nearer to, but does complicate, the discussion about rights as it relates to professional practice. This idea meant that you could not give up the capacity for private judgement, e.g. about religious questions, regardless of any external contracts or oaths to religious or secular authorities, so that right is also, here we go again, ‘unalienable’ according to Hutcheson (1755):

Thus no man can really change his sentiments, judgments, and inward affections, at the pleasure of another; nor can it tend to any good to make him profess what is contrary to his heart. The right of private judgment is therefore unalienable. (Hutcheson, 1755: 261–2)

In contrast, a thing, say, a piece of property, can, in fact, be transferred from one person to another. According to Hegel, the same would not apply to those aspects that make one a person:

The right to what is in essence inalienable is imprescriptible, since the act whereby I take possession of my personality, of my substantive essence, and make myself a responsible being, capable of possessing rights and with a moral and religious life, takes away from these characteristics of mine just that externality which alone made them capable of passing into the possession of someone else. When I have thus annulled their externality, I cannot lose them through lapse of time or from any other reason drawn from my prior consent or willingness to alienate them. (Hegel, 1967: 66)

In discussion of social contract theory, ‘inalienable rights’ were said to be those rights that could not be surrendered by citizens to the sovereign. Such rights were thought to be natural rights, independent of positive law. Some social contract theorists reasoned, however, that in the natural state, only the strongest could benefit from their rights. Thus, people form an implicit social contract, giving up their natural rights to the governing authority to protect the people from abuse, and living under the legal rights of that authority.

As no people can lawfully surrender their religious liberty by giving up their right of judging for themselves in religion, or by allowing any human beings to prescribe to them what faith they shall embrace, or what mode of worship they shall practise, then neither can any civil societies lawfully surrender their civil liberty by giving up to any external body their power of legislating for themselves and disposing of their property. In other words, no group of people can give up their right to choose a religion – or not to choose one – or set laws for them or dispose of their own property.

The 1948 Universal Declaration of Human Rights asserts that rights are inalienable:

recognition of the inherent dignity and of the equal and inalienable rights of all members of the human family is the foundation of freedom, justice and peace in the world.

The Council of Europe was established in 1949 after the Second World War to promote human rights, democracy and the rule of law in its member states and essentially be a barrier against further devastating conflicts. It includes the European Convention on Human Rights 1950, which has been incorporated into UK law by way of the Human Rights Act 1998. The European Court on Human Rights has jurisdiction over UK law and appeal to it is possible, especially for human rights issues. The Committee against Torture is a monitoring body which includes oversight of mental hospitals and regularly visits countries to inspect them. It does not have the resources to inspect all hospitals but does have the right to do so. The Council of Ministers of the Council of Europe issued a recommendation on psychiatry and human rights in 2004 and this has implications for mental health services. It includes reference to the importance of professional standards and regulatory bodies (referred to later) and also an oversight commission in each country. This was the Mental Health Act Commission in the UK but this function now forms part of the remit of the Care Quality Commission.

International documents establishing legal rights

• The Magna Carta (1215, England) required the King of England to renounce certain rights and respect certain ...

Table of contents

• Cover
• Half Title
• Publisher Note
• Title Page
• Copyright Page
• Contents
• About the Authors
• Acknowledgements
• List of Abbreviations
• Introduction
• 1 General Principles of Values and Ethics
• 2 Concepts in Clinical Ethics
• 3 Implications for CBT Technique
• 4 Considering Therapist’s Responsibilities and Boundaries
• 5 Confidentiality and Record Keeping
• 6 Professional and Therapeutic Competence in CBT
• 7 Research and Evidence
• 8 The Ethics of Using a CBT Approach
• 9 Specific Populations
• Conclusion Ethical Decision-Making
• References
• Index