Cognitive Behaviour Therapy in the Real World

Back to Basics

Henck Van Bilsen

• Publisher: Routledge
• Year: 2018
• Print ISBN: 9781780490298
• eBook ISBN: 9780429912122
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

This book provides an introduction to cognitive behaviour therapy in combination with a transdiagnostic perspective on mental health problems. It presents an overview of assessment and formulation strategies that enable therapists to compose individualised treatments for their clients.

CHAPTER ONE

Cognitive behaviour therapy in the front line

Introduction

The origins of cognitive behaviour therapy (CBT) can be traced back to some early attempts to apply learning theory to behaviour change (Watson & Rayner, 1920). Further theorising and laboratory experimentation on learning theory was done by Skinner (1938), Mowrer (1950) and Salter (1949). It took more than three decades between the first experimental studies on basic learning processes and the formal beginnings of the behavioural component of what we now know as CBT to emerge.

The development of CBT took place in three continents: Africa, Europe, and the Americas. Wolpe (1964), in South Africa, published the first structured treatment protocol: reciprocal inhibition to treat anxiety problems. Eysenck (1963) published accounts of treatment methods such as desensitisation, negative practice, and aversion therapy, all methods grounded in learning theory. Eysenck was the first to bring these various interventions together under the name behaviour therapy (BT) (Farmer & Chapman, 2007). The application of operant learning principles in therapeutic settings was developed in the USA in the application to children’s problems and people with learning disabilities (Lovaas, 1987). The term coined here was behaviour modification. The behavioural wave was further developed by Ullman and Krasner (1975). Based on earlier work by Kelly (1955), Beck (1963), and Ellis (1958, 2004), it took until the 1980s before cognitive behaviour therapy as we know it today was firmly established. A further influence was Bandura’s (1969, 1986) social learning theory.

A core element of cognitive behaviour therapy (at least, when I was trained in it) is a strong emphasis on the cognitive mediation of behaviour and the application of learning principles to bring about change. The focus of cognitive behaviour therapy is the application of these cognitive psychology principles and learning theory principles to the problems of the individual client. Cognitive behaviour therapists are like experienced chefs in a kitchen; they can follow the instructions of a cookbook, but they also can make a good meal without following a cookbook by using their knowledge about food, preparation of food and taste. Clark (2004) stresses the importance of the interplay between theories, experimental science, and clinical practice to produce clinical innovation.

Sometimes the development of CBT is described in waves (Öst, 2008). Hayes (2004) described the so-called third wave of BT:

Grounded in an empirical, principle-focused approach, the third Cognitive wave of behavioural and cognitive therapy is particularly sensitive to the context and functions of psychological phenomena, not just their form, and thus tends to emphasize contextual and experiential change strategies in addition to more direct and didactic ones. These treatments tend to seek the construction of broad, flexible, and effective repertoires over an eliminative approach to narrowly defined problems, and to emphasize the relevance of the issues they examine for clinicians as well as clients. The third wave reformulates and synthesizes previous generations of behavioural and cognitive therapy and carries them forward into questions, issues, and domains previously addressed primarily by other traditions, in hope of improving both understanding and outcomes. (Hayes, 2004, p. 658)

The third wave consists of a range of creative and often inventive clinical applications, such as: dialectical behaviour therapy (Linehan, 1993); acceptance and commitment therapy (Hayes, 2004; Hayes, Barnes-Holmes, & Roche, 2001); mindfulness (Teasdale et al., 2000); schema focused therapy (Young, Arntz, & Giesen-Bloo, 2006; Young, Klosko, & Weishaar, 2003). Many of these approaches are detailed descriptions of one specific technique, such as mindfulness or schema focused therapy, or a set of interventions packaged together as a comprehensive treatment for one identified disorder (dialectical behaviour therapy). I will not go into describing these new branches to the tree of CBT; what is striking, however, is the disparity in development of these various branches. Some are presented as therapeutic interventions after lengthy theoretical investigation, culminating in Randomised Controlled Trials (RCT’s) demonstrating the effectiveness. Some interventions or treatments seem to follow the research strategy suggested by Clark (2004), which is that the final step is to make treatments more broadly available through dissemination studies. Acceptance and commitment therapy (ACT), which proposes a comprehensive additional perspective to the behavioural and the cognitive components in CBT and mindfulness, would fall in this group. At the other end of the spectrum, there is schema-focused therapy, which was disseminated through books, workshops, and conference presentations before any clinical trials had been concluded. Compare this with ACT, which only presented itself after a range of research trials had been completed. Dialectical behaviour therapy is somewhere in the middle. It is a serious and innovative attempt to design an effective intervention for a complex client group, but its initial claim to fame was one study with a specific client group and, subsequently, it was “advertised” as the treatment of choice for personality disorders. In comparison, mindfulness, which is based on a solid research tradition, has many clinical trials demonstrating its effectiveness in relapse prevention for depression (Segal, Williams, & Teasdale, 2001). It is, however, advertised as a panacea for many clinical problems and, as such, the advertising is ahead of the evidence.

The first wave of CBT was firmly founded in empirical research: therapy techniques and procedures were often directly derived from procedures that had been demonstrated to be effective in animal research (Clark, 2004). The second wave was based on Beck’s clinical observations followed by the work of his clinical team (Beck, 1967; Beck, Rush, Shaw, & Emery, 1979), a model that was mirrored by the work of Ellis in New York. The theoretical underpinning of the work of these cognitive therapists was carried out later (Teasdale, 1977, 1983, 1988; Teasdale & Bancroft, 1977; Teasdale & Barnard, 1993). This demonstrates an interesting gap between the development of a clinically inspired theory of depression and the scientific evidence that supports it. The link between theory, evidence, and clinical practice in the third wave is even more variable. Let me make clear that third wave interventions are often very creative and examples of “outside the box” thinking, which should be admired. However, in some cases, the creative insights and practices are not followed up with enough rigorous research, as confirmed by Öst (2008).

Simultaneously with the third wave, another, and, dare I say, a less forward-moving, wave has been at work. The fourth wave of CBT is what I would call the protocolised medicalisation of CBT. It has been demonstrated (Kinderman, 2005; Kinderman & Tai, 2006) that a psychological model is far superior in explaining problems such as depression and anxiety. Within the field of CBT, it has also been argued that a focus on DSM/ICD diagnostic classifications is not helpful (Harvey, Watkins, Mansell, & Shafran, 2004). The development in mainstream cognitive behaviour therapy seems to have gone completely in the opposite direction, especially in the UK. Books focusing on CBT for specific disorders are published in abundance. CBT protocols for specific and identifiable DSM/ICD classifications are produced in vast numbers. The “Improving Access to Psychological Therapies” (IAPT) programme in the UK is a psychological therapy programme in name only, since the treatments are based on disorder-specific protocols and it is stressed that treatment needs to be preceded by having a DSM-IV or ICD-10 classification. This is made clear in two pivotal documents relating to the IAPT programme: the IAPT Implementation Plan: National Guidelines for Regional Delivery (Department of Health, 2008) and The Competences Required To Deliver Effective Cognitive and Behavioural Therapy for People with Depression and with Anxiety Disorders (Roth & Pilling, 2007). Both documents focus strongly on disorder specific and protocol-driven CBT interventions. The assumption in these documents is that the specific disorders are real entities and that clients can be fitted into boxes of diagnostic categories. This fourth wave implies that many of the great achievements of cognitive behaviour therapy are ignored and that the clock is being turned back. The development of CBT had achieved a feasible alternative to the psychiatric/medical model of framing psychological problems: a psychological model (Kinderman, 2005). Another element of the fourth wave is the increasing protocolisation of “ordinary” CBT, as evidenced by the use of tick-box-type competence measurement instruments, such as the revised cognitive therapy scale (CTS-R) (Blackburn et al., 2001), as the yardstick for competent CBT.

Some critical thoughts about the current state of CBT

There are some problems with elements of the third and fourth wave. The inclusion of many interventions that have little or no theoretical link with the founding theories of CBT and had little or no backing from empirical research has stimulated the development of a range of interventions presented as part of CBT that do not have a solid evidence base. In itself, there is no harm in this; great things happen when clinicians try things out (as demonstrated by Beck and Ellis when they stopped following psychodynamically informed treatment models), report about it, and repeat the process until a new or better intervention is developed, which, subsequently, is tested with reputable research methods. However, what happened in the third wave is that some of the “inventions” were promoted, with little evidence to support the claim, as evidence-based interventions, and they were presented in the same light as CBT for depression. The firm connection of therapeutic techniques with the theories underpinning CBT was less well established and empirical support for some of these interventions is very thin (Öst, 2008). A prime example of an approach that was widely disseminated before any empirical studies had demonstrated its effectiveness is schema-focused therapy. The first randomised controlled trial (Gie...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• Acknowledgements
• About the Author
• Introduction
• Chapter One Cognitive behaviour therapy in the front line
• Chapter Two Structuring the process of CBT and structuring CBT sessions
• Chapter Three Assessment, engagement, and formulation in cognitive behaviour therapy
• Chapter Four Cognitive behaviour therapy from a new perspective: different strokes for different folks
• Chapter Five Making sense of the facts: formulation and treatment planning in cognitive behaviour therapy
• Chapter Six Cognitive behaviour therapy strategies focused on altering antecedent cognitive appraisals
• Chapter Seven Cognitive behaviour therapy methods for modifying emotion-driven behaviours
• Chapter Eight Cognitive behaviour therapy techniques focused on preventing emotional avoidance
• Chapter Nine Measuring competence in cognitive behaviour therapy
• References
• Index