Cognitive Behavioural Therapy

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					Cognitive Behavioural Therapy

 A Conceptual and Historical Overview
              M Worrell 2010
• To attempt to define the ‘essence’ of CBT
• To place CBT in historical context
• To describe important contemporary
  developments and controversies in the field
                  Defining CBT
• Salkovskis (2002):
• “A set of empirically grounded clinical interventions.”
• These interventions must be understood as direct
  expressions of an explicit, sophisticated and
  continually developing, theoretical model(s) of the
  nature of psychopathology and the processes of
  human change.
                  Defining CBT
• There is no single unitary thing called CBT.
• Mahoney and Arnkoff (1978): cognitive therapy, RET,
  problem solving therapy, coping skills training, stress
  inoculation training, etc.
• Contemporary models: functional analytic therapy
  (Kohlenberg and Tsai, 1991), dialectical behaviour
  therapy, (Linehan, 1993), acceptance and
  commitment therapy (Hayes, et al, 1999), schema
  therapy (young et al, 2003).
               Defining CBT
• Beck’s CBT as the foundational model.
• Strong empirical support and growing
• Attracted considerable criticism and challenge.
• CBT may also be viewed as an integrative
  Who ‘owns’ the idea that Cognition
        mediates Emotion?

Popular wisdom:
  – “It’s all in your
  – “Think positive.”
  – “It’s the thought
    that counts.”
            CBT In Historical Context

• Ancient Greek philosophy-
  emphasized the effects of
  beliefs on psychological
• “Such as are thy habitual
  thoughts, such also will be
  the character of thy mind;
  For the soul is dyed by the
  thoughts” (Aurelius).
• Man’s highest good lies in
  his reason.
• People are disturbed not
  by events, but the views
  which they take of them.
• At the heart of every
  aversion and desire lies a
  value judgment.
• We have the power to
  change our situations.
• Change is our
• We should question
  ourselves, rather than
  the world.
• Advocated the maxim
  ‘know thyself.’
• A great orator and
  master at exposing false
• Also known as the
  ‘gadfly of Athens’.
         Socratic Dialogue in CBT
•   Open ended questions.
•   Questions are context dependent.
•   Driven by (respectful) curiosity.
•   Searching for new perspectives.
•   Emphasises ‘what?’; ‘How?’; ‘Who?’;
    ‘Where?’ Rather than ‘why?’ Questions.
   Influences on Aaron Beck’s CBT
• Psychoanalysis.
• Phenomenology.
• Personal construct
• Behaviour therapy.
• Humanistic psychology.
  The Influence of Psychoanalysis
• A negative influence.
• Beck’s studies on dreams.

• Ego psychology- Karen Horney:
• “The tyranny of shoulds.”
 The Influence of Phenomenology
•    Edmund Husserl
•    A study of consciousness
•    An emphasis on description
•    Three steps:
1.   Bracketing
2.   Description
3.   Horizontalisation
    The Influence of Personal Construct
•   George Kelly.
•   Persons as active interpreters of experience.
•   Personal scientists.
•   The personal construct system.
  The Influence of Behaviour Therapy
• Active and directive methods of achieving
  focused change.
• Making changes to behaviour directly.
• Measurement and monitoring of progress.
        The Influence of Humanistic
• Carl Rogers- Person Centred Therapy.
• The core conditions of Therapeutic Change.
1. Congruence.
2. Unconditional positive regard.
3. Empathy.

Beck: Necessary but not sufficient.
       CBT In Historical Context
• Contemporary situation:
• Strongly supported in the climate of evidence
  based practice and clinical governance.
• Nice guidelines & IAPT.
• The limitations of EBP- Salkovskis (2002).
  Theoretical Foundations of CBT
1. The primacy of cognition.
• An active information processing system.
• Achieving change in cognitive content,
   processes and structures is seen as the most
   effective means of achieving clinically
   significant change.
• Technical eclecticism.
       The Primacy of Cognition
• Levels of cognition:
1. Automatic thoughts.
2. Conditional
3. Core beliefs.
4. Schemas.
5. Modes.
    Theoretical Foundations of CBT
2. CBT is a mediational theory.
•   Cognitive content, process and structures directly
    influence emotional experience and behaviour.
•   Causation is not claimed.
•   Debates over the direction of influence between
    cognition and emotion.
  Theoretical Foundations of CBT
• 3. CBT is an empirical approach.
• Operational definition and measurement of
• Cognitive content can be accessed and
• Not all cognitive content or processes are
  subject to control or consciously experienced.
  Theoretical Foundations of CBT
• 4. CBT is a ‘here and now’ therapy.
• Current cognitive factors are central in the
  maintenance of psychopathology.
• Contemporary focus on developmental factors
  in schema focused therapy.
    Defining Procedural Features of CBT
•   A short term focused therapy.
•   Structured sessions.
•   Clearly defined goals- use of measurement.
•   Principle of ‘collaborative empiricism.’
•   Development of shared formulation.
•   Co-constructed homework tasks.
•   A positive collaborative relationship.
 Controversies and Developments
• CBT applied to wider range of more severe
  clinical presentations.
• Challenges to standard Beckian CBT from both
  within and outside of CBT.
• The role of the therapeutic relationship.
• The influence of social constructivism.
• The development of schema focused therapy.
Controversies and Developments
 • Computerised CBT.
 • Hayes at al (2004)- third
   wave CBT?
 • 1st wave: Behaviourism.
 • 2nd wave: Cognitivism.
 • 3rd wave: acceptance,
   mindfulness, attachment,
   relationship etc.
Post-Rationalist Cognitive Therapy
Bruner (1987): two different types of ‘knowing’:
• Paradigmatic: scientific, logical problem-
• Narrative: telling stories about self, to self and
• Principle function of mind is world making not
  logical thought.
  Renewed Interest in the Therapeutic Relationship
                 (Safran & Segal)

• Theory and practice need to be refined in the
  light of interpersonal theory.
• Role of interpersonal schema (a generic
  cognitive representation of self-other
  Renewed Interest in the Therapeutic Relationship
                 (Safran & Segal)

• Cognitive structures underlying clinical
  problems are interpersonal schema,
  embedded in cognitive-interpersonal cycles.
• Aim of therapy is to provide experiential
  disconfirmation of dysfunctional interpersonal
    Links to Cognitive Psychology
• Historically the link between CBT and
  Cognitive Psychology has been weak.
• Current models of multi-level and parallel
  processing systems in memory
• Teasdale: Interactive Cognitive Subsystems
• Brewin: Retrieval Competition hypothesis
• A de-emphasis on logical strategies?
Mindfulness-Based Cognitive Therapy

  • Paying attention in a
    particular way: on purpose, in
    the present moment and
  • Fostering a ‘decentred’
    relationship to mental
    contents by training clients to
    take a wider perspective.
  • Recognising thoughts as
    thoughts – not ‘you’ and not
        Conceptual Challenges
• Is mindfulness consistent with cognitive
• Are the underlying approaches to treatment
  compatible? If not, does this matter?
• Helpful refinement or unhelpful dilution?
             What of the Future?
•   Move towards integration?
•   Greater emphasis on the therapeutic relationship?
•   Transdiagnostic models?
•   Greater emphasis on schema-focused approaches?
•   Greater emphasis on mindfulness-based CT?
•   A multitude of cognitive behavioural therapies?
•   The challenge of dissemination & Training
•   Political factors: the relative success of IAPT
•   The impact of competency frameworks

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