Cognitive Behavior Therapy in Counseling Practice

Jon Sperry, Len Sperry

• Publisher: Routledge
• Year: 2017
• ISBN:
  9781317234531
• Edition: 1
• Topic: Psychology
• Subtopic: Cognitive Psychology & Cognition
• Index: Psychology

This Cognitive Behavior Therapy text is brief, practical, comprehensive, and tailored just for counselors. Evidence-based CBT techniques are specifically adapted to counseling including core-counseling concepts such as social justice, strengths, wellness, and diversity (e.g., ethnicity, culture, sexual orientation, gender, disability) which are interwoven throughout the book's content. Each chapter includes case vignettes that reflect the work of professional counselors in school, clinical mental health, marital and family, and rehabilitation settings.

Chapter 1

The Practice and Evolution of CBT

Counselors tend to approach the therapeutic process differently than other mental health professionals. Specifically, counselors embrace a shared philosophy of counseling in which they attempt to de-pathologize human suffering by conceptualizing the integration of a developmental perspective with a wellness model of mental health. Additionally, they focus on prevention and early intervention, emphasize client empowerment and the therapeutic relationship, and highlight multicultural competency (Fuenfhausen, Young, Cashwell, & Musangali, 2017). Further, these values are exemplified in the American Counseling Association (ACA) definition posted on the ACA website (www.counseling.org): “Counseling is a professional relationship that empowers diverse individuals, families, and groups to accomplish mental health, wellness, education, and career goals.” Given these stated values, it is not surprising that counselors tend to view Cognitive Behavior Therapy (CBT) differently than other mental health professionals.

This chapter describes the way in which CBT has been practiced over the years from the 1960s through today, and how it is likely to be practiced tomorrow. CBT has evolved over the years and we will discuss its “three waves.” As noted in the Introduction, counselors today seem to resonate with the overall values of these new “third wave” approaches since they emphasize the therapeutic relationship, identification of client strengths and resources, sensitivity to diversity and culture, and client empowerment, which are deeply held values for most counselors.

This chapter will introduce these third wave approaches as well as the more traditional first and second wave CBT approaches. It begins with a thumbnail sketch of the evolution in terms of waves. Then separate sections briefly describe each of the waves: first wave, second wave, and third wave. Next, we will highlight the evidence-based support of CBT approaches and also review research on clinical outcomes in counseling. Finally, the chapter will close with a brief discussion of the therapeutic relationship and multicultural competence and sensitivity.

Evolution of CBT

For the last five decades, Behavior Therapy, Cognitive Therapy, and CBT were the treatments of choice for the psychosocial treatment of various mental health disorders. While research did not consistently support the efficacy of these traditional modalities with various disorders, it has for newer, more focused approaches such as Dialectic Behavior Therapy (DBT) and Mindfulness-Based Cognitive Therapy (MBCT). Interestingly, DBT and MBCT, along with Acceptance and Commitment Therapy (Hayes, 2004), constitute what is being called the “third wave” of Behavior Therapy (Hayes, Follette, & Linehan, 2004).

Since the 1970s, the field of psychotherapy has shifted from psychodynamically oriented, long-term psychotherapy to more problem-focused, short-term therapies such as variants of CBT. These counseling approaches—particularly Behavior Therapy, Cognitive Behavior Therapy (CBT), and Interpersonal Psychotherapy—have been shown to play a significant role in the treatment of specific psychiatric disorders (Craighead & Craighead, 2001). In fact, randomized clinical trials show them to be particularly effective as primary treatments (i.e., treatments of choice, for obsessive-compulsive disorder, panic disorder, and major depression). They are also effective as adjunctive interventions with medications for bipolar disorder and schizophrenia. In addition, they play a substantial role in educating patients about their disorders, explaining treatment rationales, and encouraging treatment compliance, especially when medication is involved (Craighead & Craighead, 2001).

First Wave

The first wave refers to traditional Behavior Therapy concepts such as reinforcement techniques and classical conditioning, which focused on modifying or replacing maladaptive behaviors. Early Behavior Therapy was a concrete, problem-focused, technical, and here-and-now approach that was markedly different than client-centered therapy, psychoanalysis, and similar approaches of the era that emphasized the therapeutic relationship and the client’s inner world. Behavior Therapy researchers and clinicians initially emphasized interventions that were used to establish a scientific basis to effectively treat specific anxiety disorders.

Joseph Wolpe was one of the original developers of Behavior Therapy. His approach was based on his theory of “reciprocal inhibition” (Wolpe, 1958, 1990). Wolpe believed that if anxiety-producing stimuli occurred simultaneously with an inhibition of anxiety—such as being in a relaxed state—the bond between those stimuli and the anxious symptoms would be reduced. His primary contribution was “systematic desensitization” that was a protocol in which a hierarchy of anxiety-producing stimuli was constructed. Then, when the client was in a deep state of relaxation, each stimulus would be gradually introduced until they no longer produced anxiety. This rather time-consuming intervention would in time be eclipsed by exposure therapy. Other notable behavior therapists were Isaac Marks and Albert Bandura.

Unfortunately, when systematic desensitization was subjected to the research method known as “dismantling,” the unmistakable conclusion was that direct exposure was the only behavioral intervention required for behavior change. It did not require any of the other interventions assumed by Wolpe to be necessary to achieve the goal of reduction of anxiety. Not needed were the establishment of a hierarchy, the presence of a relaxed state, or the gradualness of exposure that Wolpe claimed were necessary. In short, the conclusion was that only direct exposure was the necessary and sufficient condition for therapeutic change. As a result of these findings, Wolpe’s (1958) theory of reciprocal inhibition was soon discarded. Today there is little question that exposure therapy is a treatment of choice for a number of conditions, and very few know much about systematic desensitization, except as a historical footnote. Besides exposure, there are several highly effective behavioral interventions in practice today. They include behavioral activation, behavioral rehearsal, skills training, habit reversal, and impulse control training. These and other techniques are described in detail in Chapter 5.

The first wave counseling process was not relationship focused in the way counselors typically describe it, but a concern for the client was clearly involved. A telling example of this is the use of the Subjective Units of Distress Scale (SUDS) (Wolpe, 1958), which is a self-rating scale of emotional pain and suffering in which the client is taught to rate their subjective units of distress on a 1–100 unit scale. Through ongoing self-assessment, clients increase their level of control over their symptoms. As a result of the counselor teaching this empowering method, they demonstrate a high level of regard for the client’s well-being, of which clients are most appreciative. By the use of this and other behavioral methods, counselors who use this scale demonstrate sensitivity to the therapeutic relationship. Of particular note, some of the original behaviorists were not known to consider the therapeutic relationship to be a primary change mechanism in the counseling process.

Second Wave

The second wave involved the incorporation of the cognitive dimension into the counseling process. It did so by focusing on reducing depressive affects and behaviors by changing the thoughts that cause and perpetuate them (Beck, 1967; Beck, Rush, & Emery, 1979). Aaron T. Beck’s work is credited as the starting point of the second wave even though others had previously developed cognitive-focused therapies. Beck called his approach Cognitive Therapy and initially it emphasized cognitive restructuring; only later were behavioral interventions such as behavioral activation added.

The incorporation of cognitive and behavioral therapies in the 1970s was not initially a cordial or conflict-free union. Today most cognitive counselors incorporate key behavioral interventions while many behaviorally focused counselors recognize the role of clients’ beliefs about the consequences of their behaviors. The fact that both were problem-focused and scientifically based therapies has helped foster this union, resulting in CBT becoming the most commonly practiced treatment method in the United States since the late 1980s.

Rational Emotive Behavior Therapy (REBT) is of the first of the Cognitive Behavior Therapies, developed by Albert Ellis. This approach is still widely practiced today. REBT theory explains human suffering by identifying that negative emotions are influenced by unrealistic and inflexible beliefs and that individuals actively disturb themselves by assuming that their thoughts are the ultimate truth. Aaron T. Beck’s work on cognitive therapy was presented around fifteen years after Ellis first wrote and presented on REBT.

Both were formally trained analysts who believed psychoanalysis was an insufficient approach to helping individuals with mental health issues and both developed very similar psychological treatment approaches that emphasized cognition as the mechanism of suffering and the mechanism of change in counseling. They were initially unaware of one another’s theories and developed the approaches independently from each other.

Both Ellis and Beck credit Adler’s contribution to their approaches, particularly the primacy of cognition in the change process. Ellis credits Alfred Adler, Karen Horney, and Epictetus among others as influential in his creation of REBT. Further, in a letter written to the North American Society of Adlerian Psychology (NASAP) by Aaron Beck in 1989, he respectfully declined an offer to provide a keynote lecture at the annual NASAP conference, but stated that he considers himself an Adlerian.

Alfred Adler is considered the first cognitive-behavioral practitioner based on his writing and practice of his therapy approach, Individual Psychology, also known as Adlerian Psychology (Freeman, 1981). One of Adler’s many contributions included paving the way for cognitive-behavioral therapeutic approaches including Ellis’s Rational Emotive Behavior Therapy and Beck’s Cognitive Therapy (Mosak, 2005). Adler conceptualized maladaptive behavior to be influenced by one’s “private intelligence,” later called “faulty logic,” which informs one’s view of self as well as views and expectations of others. Freeman noted that Ellis and Beck “credit their training in Adlerian and Horneyan models as central to their formation of a cognitive model of psychotherapy” (1983, p. 1–2).

The role that Cognitive Therapy (CT) played in the evolution of CBT has already been discussed, and it is particularly noteworthy to mention that proponents of CT/REBT publish in the Journal of Individual Psychology, the flagship journal of Adlerian Psychology. One such individual, Ellis (1970), stated, “Adler strongly influenced the work on Sullivan, Horney, Fromm, Rogers, May, Maslow, and many other writers on psychotherapy, some of whom are often called neo-Freudians, when they more correctly could be called neo-Adlerians” (p. 11). See Watts and Critelli (1997) for a comprehensive discussion of the influence that Alfred Adler has had on CBT and other contemporary forms of psychotherapy. Two separate issues published in the Journal of Individual Psychology (volume 73, 2017) contain comprehensive coverage of Adler’s influence on contemporary therapeutic approaches, including CBT.

Third Wave

In the third wave approaches, treatment tends to be more experiential and indirect and utilizes techniques such as mindfulness, acceptance, dialectics, values, and spirituality (Hayes et al., 2004). More specifically, third wave approaches are characterized by “letting go of the attempts at problem solving, and instead standing back to see what it feels like to see the problems through the lens of non-reactivity, and to bring a kindly awareness to the difficulty” (Segal, Williams, Teasdale, & Williams, 2004, p. 55, italics added). Unlike the first and second wave approaches, which were based on a modernist assumption of human nature, first-order change (symptom reduction), and a de-emphasis on the therapeutic relationship, third wave approaches are quite different. Besides being based on post-modern assumptions, second-order change (i.e., basic change in personality structure and/or function), and a sensitivity to the client and the importance of the therapeutic relationship, they are also based on contextual assumptions including the influence of culture. Third wave approaches such as Acceptance and Commitment Therapy, Dialectical Behavior Therapy, Cognitive Behavioral Analysis System of Psychotherapy, or Strengths-Based Cognitive Behavior Therapy place a significant focus on the therapeutic relationship. These approaches are discussed below.

Acceptance and Commitment Therapy

Acceptance and Commitment Therapy (ACT) was developed by Steven Hayes. Note that it is referred to as “ACT” to emphasize action and behavior change, and not A.C.T. when speaking about the approach with acronym abbreviation. It is based on relational frame theory, which is its underlying approach to human language and cognition. ACT is also based on functional contextualism, which means that instead of viewing clients as disordered or flawed like many other approaches, it focuses instead on identifying the function and context of behavior (Hayes, 2004).

One of the goals of ACT is to assist individuals to increase their acceptance of difficult and painful experiences and to increase their commitment to action that can improve and enrich their lives. ACT assumes that suffering results from the avoidance of emotional pain rather than the experience of it. Instead of a symptom-reduction approach like other treatment approaches, the goal of ACT is to learn how to accept and detach from symptoms. Therefore, when acceptance occurs, symptom reduction is a byproduct. ACT treatment involves the use of metaphors, behavioral interventions, exercises, and mindfulness skills training. It uses mindfulness skills to develop psychological flexibility, clarify, and foster values-based living.

Dialectical Behavior Therapy

Originally developed to treat individuals diagnosed with borderline personality disorder (Linehan, 1993), Dialectical Behavior Therapy (DBT) has been modified and extended to treat individuals with other personality disorders as well as mood disorders, anxiety disorders, eating disorders, and other destructive behaviors such as self-harm, suicidal ideation, and substance use disorders (Marra, 2005; Lynch & Cuper, 2012). DBT is an extension of Behavior Therapy but is less cognitively focused than traditional CBT since DBT assumes that cognitions, per se, are less important than affect regulation. Accordingly, DBT places more emphasis on coping skills and emotion regulation rather than modifying distorted thoughts or irrational beliefs. While it recognizes that perception and cognitive processes are a factor in behavior, they are not conceptualized as a mediating factor. Further, DBT assumes that individuals are doing their best but are lacking some specific skills, thereby interfering with their capacity to manage their feelings or reactions.

Additionally, a DBT conceptualization of human suffering can be understood by

identifying deprivational emotional states in early development that could have produced fixation or perseveration and attentional constriction that could serve as protection from threatening internal or external cues, as well as broadly examining the effects of negative reinforcement through emotional escape and avoidance strategies or inadequate psychological coping skills that could have been rewarded through the partial reinforcement effects.

(Marra, 2005, p. 141)

Cognitive Behavioral Analysis System of Psychotherapy

Cognitive Behavioral Analysis System of Psychotherapy (CBASP) is a counseling approach developed by McCullough (2000) and further elaborated by McCullough, Schramm, and Penberthy (2015). Basic to this...