Integrating CBT and Third Wave Therapies

Distinctive Features

Fiona Kennedy, David Pearson

• Publisher: Routledge
• Year: 2020
• ISBN:
  9780429810534
• Edition: 1
• Topic: Psicologia
• Subtopic: Storia e teoria della psicologia

Integrating CBT and Third Wave Therapies offers a thought-through approach to integrating evidence-based therapies. It provides help for all of us who are developing or have expertise in a variety of evidence-based approaches.

The theoretical part of the book briefly reviews four therapies, namely: CBT, DBT, ACT and CFT. The authors identify core processes of change and examine how each therapy contributes to each core process, helping in the integration of all four. The text considers the influence of early adversity on later mental wellbeing, the theoretical underpinnings of mindfulness, behaviour analysis, reliving and re-scripting and dissociation. Theory and practice chapters are illustrated using case vignettes.

The book will be useful for therapists to structure sessions with clients. It demonstrates how to follow a theoretical approach andoffers a therapeutic structure for integrated clinical work. It will be useful in reflective practice and supervision, and for students learning about a variety of therapeutic approaches.

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Introduction

This book is for therapists and other people in helping roles. It is designed to stand alone or to be used alongside our book Get Your Life Back: The Most Effective Therapies for a Better You, which is written for clients (and therapists) to use directly as a work book. This current book addresses how to integrate four of the most popular evidence-based therapies in use at the moment: CBT (cognitive behaviour therapy) and three ‘third wave’ therapies: DBT ­(dialectical behaviour therapy), ACT (acceptance and commitment therapy) and CFT (compassion focused therapy). Each of these therapies has developed and expanded to include applications to a wide variety of client presentations and has incorporated mindfulness and acceptance focused interventions. Each has borrowed and includes interventions and concepts from the others. Although there is a lively debate about similarities and differences between the approaches, particularly as to the role and importance of cognitions and the processes of change, they have many theoretical and practical aspects in common.

In the first part of this book, the basic theory of each approach is outlined ‘in a nutshell’. Theoretical similarities and differences are examined, as are ways to resolve or tolerate apparent conflicts between theories. Fundamental theoretical principles and core processes of change are discussed. We see these as key to a new therapy, CBT+, which integrates the four approaches. The second part of the book uses clinical vignettes as practical illustrations. It offers basic therapeutic principles and a protocol for CBT+. NAVIGATES is an acronym for how to proceed with CBT+ in a way that makes sense to therapists and clients.

In Part I, Chapters 2 to 5 briefly describe in a nutshell CBT, DBT, ACT and CFT, with emphasis on the theory underpinning the practice of each therapy. A discussion of some reasons for and against integrating the approaches follows in Chapter 6. For example, it is undoubtedly the case that most clinicians are attending trainings in some or all of these therapies. We are then returning to our own practice and using the ideas and techniques we have learned. But do we have the opportunity to think through why and how we are choosing what to use from moment to moment? Another consideration is that integration is already happening, for example with the establishment of mindfulness-based CBT. DBT and ACT each borrow heavily from other approaches, including CFT. Having summarised the basic theory and practice of each therapeutic approach and discussed pros and cons of integration, we look at commonalities and differences between CBT, DBT, ACT and CFT. We argue that a dialectical stance is needed where apparent opposites can be held in mind simultaneously. When we think about how to describe light, we need to think about both waves and particles to fully account for its behaviour; when we think about human beings, we need to hold apparently contradictory concepts in mind to fully account for our behaviour. A contextualist approach, where everything can be understood only within its context, forms the basic philosophical platform on which to build an integrated therapy.

Chapter 7 expands on the behavioural underpinnings of CBT+. By looking at what we know about processes of change in therapy, Chapters 8 and 9 show how we can aim to guide clients through core processes of change.

The acronym NAVIGATES is introduced in Chapter 10, as a memory aid or protocol to describe what needs to happen in CBT+ therapy to turn all this theory into practice.

In Chapter 11 we take some time to understand why childhood trauma of various kinds is so important in the development of later mental health problems. In Chapter 12 we look at the theoretical underpinnings of mindfulness, and in Chapter 13 behavioural theory. Chapter 14 explores some of the theory involved in re-living and re-scripting approaches for trauma, and Chapter 15 presents some theory to help us understand dissociative responding, especially after trauma.

In Part II, the acronym NAVIGATES is looked at in more detail. Chapters 16 and 17 introduce two complex cases, Ruth and Stuart, which will be used as illustrations of CBT+ work. Teaching mindfulness to clients is the topic of Chapter 18, as it is an essential therapist stance in CBT+ and central to skills taught to clients. Chapter 19 contains useful practical mindfulness exercises. Chapter 20 shows how to get commitment and motivation from both client and the therapist. This happens before the therapy itself, using a DBT ‘pre-therapy’ approach: problems of motivation and commitment are among the blocks to change in ‘challenging’ presentations. Chapters 21 to 29 are based around the mnemonic NAVIGATES. Each letter prompts the therapist to do certain things, but with a considerable amount of discretion as to how to achieve the aim and in which order to take each step. NAVIGATES allows the therapist to guide the client through the core processes of change. The core processes of change involve: developing the ability to take new perspectives on one’s experiences and behaviour; having or acquiring the motivation and skills to act differently to one’s established habits in response to distressing emotions; reprocessing trauma, childhood abuse and neglect; and becoming willing and able to relate to oneself and others with compassion and trust.

The summary and conclusions in Chapter 30 emphasise that CBT+ is a principle-driven approach. It is not prescriptive but focused on guiding the client through the processes needed to produce therapeutic change. It seems essential that we draw on all the currently available knowledge and skills in order to do this.

Part I

The distinctive theoretical features of CBT+

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CBT in a nutshell

What is CBT?

Cognitive behavioural therapy (CBT) was one of the most important advances in therapy of the 20th century. As the name suggests, CBT developed in the 1950s and 1960s with the combination of cognitive therapy and behaviour therapy. This advance is generally attributed to Aaron T. Beck (Thomas, Pilecki & McKay, 2015).

How CBT conceptualises psychological distress

The way we think about things affects how we feel, what we do and our bodily responses. Let us take the example of Rengina. She believes she will not be able to get on the bus, because she predicts people will look at her and think bad things about her. She avoids bus stops as she feels a great deal of anxiety. She is afraid people will notice her panic and believes that her symptoms mean she might have a heart attack. She notices that when she walks away from the bus stop the horrible sickly, sweaty feelings disappear. These thoughts and feelings are the driving force for her avoidance of bus stops. Most mental health problems are driven by avoidance and anxiety. Rengina can prevent some feelings of anxiety by avoiding leaving the house so that she does not see a bus or bus stop. Of course, there are big costs of this avoidance behaviour.

If Rengina saw a therapist she might say that she is afraid of leaving the house. Leaving the house gives her sensations of panic. She feels sick, her body shakes and she has thoughts that she will have a heart attack. These are experiences that everybody would want to avoid, but interestingly not leaving the house has the advantage of reducing those awful feelings and thoughts at the bus stop. A CBT formulation would identify the components of Rengina’s experience. Beck described these components as ‘schemas’, a concept introduced by Piaget (Beck, 1967). A schema is an underlying neurological structure, formed by our previous learning or by being hardwired from birth. It determines how we interpret and respond to our environment. There are four types of schemas:

• Thoughts (‘I don’t want to leave the house in case I see a bus’; ‘I am too unwell to go out’; ‘People look at me and think I am inferior’)
• Feelings (fear, shame)
• Body sensations (nausea, fast heartbeat, shaking, breathing fast and shallow)
• Behaviour (stay at home, decide not to go out)

The CBT formulation is commonly known as a ‘Hot-cross-Bun’ or ‘Wheel of Experience’ and looks like the diagram in Figure 2.1.

Figure 2.1 Hot-cross Bun or Wheel of Experience CBT formulation

There is a fifth element to this formulation, which is the environment or context in which the schemas are activated. In Rengina’s case, this could be when she needs to go out and get shopping, meet friends, etc. Then she will start thinking about what might happen if she goes out, or else she might even just experience anxiety and all the symptoms without consciously thinking about going out. This ‘five areas model’ is explained by Williams and colleagues (e.g., Williams, 2001; Wright, Williams & Garland, 2002). The environmental triggers for responses can be internal events, such as thoughts, images, memories or body sensations (for example, Rengina thinking ‘I’m out of butter, I’ll need to go out to the shop’). They can also be external events, such as seeing a program on TV, something someone says, or the arrival of a bus at the bus stop. Certain situations may also act as ‘setting conditions’ or signals for these responses (for Rengina, the bus stop or a group of people).

A central tenet of CBT is that it is not events or situations themselves that cause distress, but the interpretation of them. This is often illustrated using the example of the ‘noise in the night’. Being woken by a crashing noise, one could think ‘Oh, it’s the cat’. In this case we might feel a little annoyed. Or we could interpret the same noise as being a burglar downstairs, in which case terror might be our response. Our internal schemas determine our interpretations and responses.

Negative thoughts can happen often and are ‘automatic’ and unquestioned by the person having them. The CBT shorthand for this is NATs (negative automatic thoughts).

Personality can be formulated as a ‘deep structure’ of ‘core beliefs’ about the self, the world and other people. These beliefs are likely to have been formed early in life and be hard to change. They lead to ‘underlying assumptions’ about the way things are, which in turn produce NATs.

For Rengina:

NAT:	‘People will stare at me on the bus’
Underlying assumption:	‘If people notice me they will think I’m weird’
Core belief:	(self) ‘I’m defective’ – (others) ‘are judgemental’ – (world) ‘is dangerous and cruel’

How does CBT help us to change?

CBT aims to change thoughts that are driving behaviours. It may also be appropriate to directly change behaviours that will in turn change thoughts. The key processes are as follows:

• The client records and reviews their thoughts with help from the therapist
• The client is helped to notice that their thoughts link to their feelings, behaviour and bodily responses
• The therapist focuses on identifying emotion-laden ‘hot’ thoughts, using a CBT formulation
• Jointly with the client, the therapist explores the problem with curiosity, using ‘Socratic’ questions about the client’s thoughts and feelings, for example ‘How do you know that?’ or ‘Where did you learn that?’

CBT teaches thought handling skills. Below are some of these skills with examples:

• Perspective taking: ‘What would someone who disagrees with you say?’; ‘Just helicopter up and look down at the situation … then decide what you want to do’
• Compassion: ‘What would a kind friend say about that?’; ‘What would you say to your own loved one if they told you this?’
• Mindfulness: ‘Can we just observe and describe this thought or feeling, without trying to change it and without getting caught up in it?’

CBT can also work to directly to change behaviour, especially when the client is stuck in avoidant inactivity:

‘Let’s get active when you feel low, don’t wait until you feel like it, perhaps using activity scheduling’

The effectiveness of CBT

This necessarily basic account of CBT does not include the vast array of adaptations of the therapy to different problems. There is an impressive amount of convincing evidence for the effec...