TBCT is a new model that, although still inherently Beckian, distinctively organizes known and standard cognitive and behavioral techniques into a step-by-step fashion in order to make cognitive therapy more easily mastered by the new therapistāmore easily understood by patients, and simpler to be implementedāwhile still maintaining flexibility and CBTās recognized effectiveness and transdiagnostic feature (de Oliveira, 2015).
TBCT development started with the publication of the Sentence Reversion-Based Thought Record (SRBTR; de Oliveira, 2007), which was a modified 5-column thought record designed to deal with āyes, but ā¦ā dysfunctional thoughts. During the elaboration of SRBTR, I used the downward arrow technique (Burns, 1980) to uncover the dysfunctional negative CBs, introduced sentence reversal (Freeman and DeWolf, 1992) to bring new positive meanings to the reversed sentences, and added the upward arrow technique (Leahy, 2003) to activate healthier positive CBs. Thus, by repeatedly using the SRBTR in session and as homework, my intention was to help the patient deactivate dysfunctional modesāa mode being defined by Beck (1996) as an interrelated sets of schemasāmodifying them in structure and content, and finally, neutralizing them by the incorporation of a more credible explanation and by the activation of more adaptive modes. Theoretically, SRBTR was explicated taking the perspective of Teasdaleās Interacting Cognitive Subsystems (ICS; Teasdale, 1996; Teasdale and Barnard, 1993). The main goal of the treatment, according to the ICS view, was to substitute the synthesis of the depressogenic schematic models that maintained depression with the synthesis of alternative, non-depressogenic models, something possible only if one succeeded in making changes at the level of higher-order meanings. According to Teasdale (1996, page 36), creating small changes like āThe man said āGO ONāā vs. āThe man said āNO GOāā (and thus changing a small part of a total pattern of the implicational code) might be sufficient to fundamentally change the high-level meaning represented. Also, Teasdale (1996) asserted that the effect of changing a thought and its related specific meaning could, by changing a discrete corresponding section of an affect-eliciting, implicational code pattern, be sufficient to change the emotional response.
However, although SRBTR seemed to be useful in helping patients to restructure their CBs, a difficulty resided within the approach. The therapist would encourage the patient to immediately confront the CBs with evidence supporting them instead of evidence against them which was often invalidating for the patients, unless a solid alliance was established. With this problem in mind, and after much reflection, the solution came to me accidentally, as an inspiration when I decided to use the courtroom metaphor after seeing the novel The Trial, by Franz Kafka (1925/1998)āwhich I had read many years beforeāin a bookstore (See Chapter 2). It was not the first time the courtroom metaphor was used in CBT (Freeman and DeWolf, 1992; Cromarty and Marks, 1995; Leahy, 2003). The idea was simply conceptualizing the CB as a self-accusation, and adding two columns to the thought record, corresponding to the evidence confirming the CB (prosecutor), and the evidence not supporting it (defense attorney). Otherwise, all the other columns received a courtroom connotation, but were kept as originally designed, preserving the downward arrow approach (Burns, 1980), the sentence reversal procedure (Freeman and DeWolf, 1992), and the upward arrow technique (Leahy, 2003). The new, now-derived, thought record was named trial-based thought record (TBTR; de Oliveira, 2008).
Preliminary results of studies supported the TBTR use in different psychiatric disorders (de Oliveira, 2008; de Oliveira, Duran, and Velasquez, 2012c; de Oliveira, Hemmany, Powell, Bonfim, Duran, Novais, et al., 2012a). Besides demonstrating its efficacy in social anxiety disorder (de Oliveira, Powell, Caldas, Seixas, Almeida, Bomfim, et al. 2012b; Powell, de Oliveira, Seixas, Almeida, Grangeon, Caldas et al. 2013), the TBTR was shown to decrease the credibility given by patients to dysfunctional negative CBs and the intensity of corresponding emotions (de Oliveira, 2008; de Oliveira et al. 2012a, 2012b). The above-mentioned studies reached the conclusion that TBTR might help patients reduce attachment to negative CBs and the intensity of corresponding emotions, irrespective of the diagnosis.
Table 1.1 shows other techniques that were progressively added to the TBTR, resulting in a new psychotherapy approach called Trial-Based Cognitive Therapy (TBCT). Such techniques were modifications of standard CBT techniques and other approaches, making TBCT an example of assimilative psychotherapy integration (Messer, 1992; de Oliveira, 2013). In this kind of integration, various techniques from different theoretical origins are incorporated within the context of understanding provided by the home theoretical approach (Stricker, 2010). Thus, since its origin, TBCT relied on Beckian CBT as the organizing theory and added technical interventions drawn from several other approaches. Among them were Gestalt therapy, compassion-focused therapy, metacognitive therapy, mindfulness, and Mitchell's (1988) two-person relational model. Furthermore, by adding literature, TBCT relied on the work of Franz Kafka, The Trial (1925/1998), and its most important techniques incorporated the courtroom metaphor, by which the patient could express multiple internal characters (e.g., prosecutor, defense attorney, witnesses, jurors, etc.) to challenge her CBs conceptualized as self-accusations (de Oliveira, 2011). As TBCT was designed as a 3-level, 3-phase, structured step-by-step approach (See Chapter 3), and its conceptualization involved a cyclic interactional mechanism in which each component in each level influenced the other, this approach has shown to be flexible enough to allow the therapist to adapt the treatment to the individual's needs and characteristics.
The case conceptualization diagram (CCD), aiming to connect all the TBCT techniques and to organize their use during therapy, was the last TBCT tool developed, marking the beginning of TBCT as an individualized approach. This idea and the name āTrial-Based Cognitive Therapyā was the result of a conversation between Robert Friedberg (PhD, Professor of Cognitive Therapy for Children and Adolescents at Palo Alto University) and myself, during the World Congress of Behavior and Cognitive Therapies (WCBCT), held in Boston, MA, from June 2ā5, 2010.
