Cognitive Behaviour Therapy, from Basic techniques to Recent by 7yZo450h


									“A Little kindness and gentleness towards yourself is a wiser and more skilful
response to feeling threatened than any amount of analytical problem solving”
(Williams et al 2007, p. 217).

Cognitive Behaviour Therapy from Basics to Recent

At a recent professional training seminar on Mindfulness,
Based Stress Reduction, Saki satorelli, (2009) one of the main
innovators, with Jon Kabat Zinn, on the introduction of
mindfulness approaches into western medicine said “there is
nothing wrong with thoughts, but some times they just might
point us in the wrong direction”. This statement indicates the
prime position of thoughts or cognitions in cognitive therapy,
and hints at two possible approaches as to how we deal with the
cognitive process. In second generation modalities, the negative
or unhelpful contents of the mind are the target of the change
process. However more recent third generation approaches
incorporate a mindfulness focus on our relationship to the
content, as Stephen Hayes proposes “a conscious posture of
openness and acceptance towards psychological events, even if
they are formally negative irrational or even psychotic…can
mean that a negative thought mindfully observed will not
necessarily have a negative function” (Hayes, 2004 p.9)
However before looking at second and third generation

approaches, it is useful to briefly examine the first generation in
this lineage of therapies, behaviourism.

First Generation: Behaviourism.
Behavioural approaches to depression focus on threat and safety
seeking behaviours. While other schools such as psychoanalysis
look at depression as resulting from inner conflicts, that are
often unconscious. “Behavioural theories focus on the outputs
and behaviours of living systems and the contexts in which
behaviours are emitted”. (Gilbert, 1992 p.63) Consequently
behaviourism is more concerned with the way a person interacts
with the world , rather than placing the source of depression in
side the person “in terms of faulty cognitions” (Gilbert, 1992 p.
63) This approach had its origin in the 1950s work of B.F.
skinner who “championed radical behaviourism, which places
primary emphasis on the effects of environment on behaviour”
( Corey, 2005 p.227) It was a departure from psychoanalytical
approaches, and focuses on how principles of learning, derived
from the experimental laboratory can be applied clinically. It is
based on theories of classical stimulus and response
conditioning, and operant conditioning, which involve learning
from the positive or negative consequences of behaviour.
Regarding the behavioural approach to depression, Ferster
(1973) proposes that a depressed client has a distorted,

incomplete and misleading view of his environment. For this
type of client there is
    A limited world view which leads to the client being
      unable to see what behaviours are appropriate for
      reinstating adequate levels of reinforcement.
    A lousy view of the world .Whereby the depressed client,
      may be aware of what behaviours are required, but fears
      the adverse consequence of such behaviour.
    An unchanging view of the world. Whereby it is not so
      much a lack of perception, or a fear of aversive
      consequences, but a lack of skills, whereby the client’s
      behavioural repertoire is not sufficiently developed.
Gilbert (1992) offers that the key points of behaviourism are a
focus on the functions of behaviour, which are individual to a
person. He see the client’s distorted view of his environment
leading to approach – avoidance conflicts and painful dilemmas
that can increase stress , and make people feel as if they are in a
fog. Therefore safety behaviours such as submissiveness and
avoidance are the client’s way of trying to regulate problematic
emotions .Furthermore emotions and fear of emotions are
common internal problems that need to be addressed in
depression. Learning how to accept, tolerate, and work with
emotions and reduce depression related behaviours is central to
many types of behavioural approach.

One such behavioural approach – Behavioural activation
Therapy – focuses less on peoples interpretation and thoughts,
and instead focuses on understanding the function of depressive
behaviours, and how to enact specific anti -depressant
behaviours. The key is to help the client to learn how depression
has altered their styles of behaviour, such as becoming more
limited or avoidant. The view is that our feelings and thoughts
are heavily influenced by our behaviours. Accordingly the client
is challenged into giving up their safety and ineffective defence
behaviours. A main principle is that what a person puts into their
lives can act as rewards and reinforcers. (Gilbert, 1992)
Subsequently Cognitive Therapy did put the B back into the
therapy that became Cognitive Behaviour Therapy, (CBT) and it
incorporates many of theses behavioural activation strategies.

Second Generation: CBT. And Schema Therapy
Cognitive behaviour therapy retained the empirical approach of
behaviourism, which Kuyen et al (2009, p.4) defined as an
approach “in which hypotheses are continually developed Based
on client experience, theory and research. These hypotheses are
tested and then revised based on observations and client feed
back.” Developed by Aron T. Beck in the 1960’s “as a result of
his research on depression” (Corey, 2005 p. 283) CBT theory is
based on the idea that instead of reacting to the reality of a
situation a person can sometimes react in an ineffective and self

defeating manner, to his own distorted viewpoint or cognitions,
that are triggered by inappropriate or irrational thinking patterns.
(Paula Ford – Martin, 2001) The client’s core beliefs- usually
developed from experiences in early childhood or adolescence, -
such as “I am a worthless person” become an established
Schema “that form the basis for the regularity of interpretations
of a particular set of circumstances” (Stanley, 2009) In the case
of depression Beck sees that the client’s negative distorted
views, are connected to what the client believes are a sense of
loss to his personal domain. Furthermore beck observed, that the
content of the clients negative automatic thoughts “tended to be
peculiar not only to the individual patient but to other patients
with the same diagnosis” (Beck, 1976 p. 105)
Therefore beck notes that “The depressed patient shows specific
distortions. He has a negative view of the world, a negative
concept of himself, and a negative appraisal of his future: the
negative triad.” (Beck, 1976 p.106) At the core of CBT is the
dynamic interaction, between the clients Thoughts, emotions,
behaviour, physical reactions, and the client’s environment, as
can be seen in Figure 1.below

Figure 1.Cognitive Behavioural Model
Source Mari Keenleyside (2007)

                                 Thoughts & Images

            Physical Reactions                     Emotions/ Moods

                                 Behaviour / Activity

As stated by Greenberger and Padesky (1995, p.4) “the.. areas
are interconnected. The connecting lines show that each
different aspect of a person’s life influences all other areas.”
This model helps client and therapist, to collaborate in
understanding what is going on for that client. It is often the first
stage, in the educative process for the client, and the beginning,
of the client and therapist developing a rudimentary case
conceptualisation. The case formulation is a hypothesis of what
is going on for the client, worked out in collaboration between
counsellor and client. The case formulation approach
“Conceptualises psychological problems as occurring at two
levels: the overt difficulties and the underlying psychological
mechanisms”. Jacqueline B Persons ( 1989, p.1) So that real life
problems such as low mood and depression are tagged to the
underlying psychological mechanisms, which are often

     expressed in terms of the afore mentioned irrational beliefs
     about the self, the world and the future. A CBT example of a
     Case formulation of Depression is shown below in figure 2.
     Figure 2 C.B.T. Case Formulation of Depression : Source Eoin Stephens (2007)
     Amalgamation of charts mine.

                                 (Early) Experience
                                 Parental Neglect

                         Schema / Core beliefs (unconditional)
                         I am a worthless Person

              Rules intermediate beliefs(conditional)                               Compensation Strategies
              To be a worthwhile person I must be loved by everyone                 Try too hard to please

                    Negative Automatic Thoughts                                      Current Trigger
                    I’ll never be loved by anyone                                    People avoid him

                                                                      Biochemical Reactions
Emotions                       Behaviour                              Tired, Little appetite
Low Mood                       Low activity

     While the case formulation helps to elaborate what is going on
     for the client regarding their automatic thoughts, assumptions,
     and core beliefs, it does not ignore behaviour. Moreover it
     guides the counsellor in the most appropriate initial intervention.

Kuyen et al state (2009, p. 26) that conceptualization “ is
original and unique to the client and reveals pathways to lasting
change” The intervention pathway can initially be a behavioural
intervention. In my experience this tends to be he case where a
client presents with a high degree of lethargy, and avoidance
behaviour. In developing the case formulation, an assessment
instrument, such as the Beck depression inventory, together with
the use of Socratic dialogue, elicits from the client what Persons
(1989) identifies as three types of problematic cognitions:
  1. Derivatives of the clients underlying irrational beliefs,
     which are automatic thoughts that also tend to be
  2. Maladaptive thoughts, which seem accurate and functional
     but focusing on them causes negative moods, impairs
     behaviour, and reinforces irrational beliefs.
  3. distorted thoughts involve an unrealistic view of reality or
     involve illogical reasoning.

An empirical CBT intervention for depression, incorporating
Persons ( 1989) case formulation approach, and Padesky and
Greenberger client manual (1995) could be as follows:
         Establish therapeutic alliance
         Assessment of clients presenting issues, relating
           these to the CBT model. Assessment may also

  include use of formal assessment instruments such as
  the Beck depression inventory.
 Initial Case formulation in collaboration with client
  using Socratic dialogue.
 Using Case formulation to identify underlying
  psychological mechanisms, and best intervention.
 Behavioural Interventions, which can include,
  activity scheduling.
 Cognitive interventions –which are at the core of
  CBT- these involve teaching the clients new skills,
  such as using a thought record to capture automatic
  negative thoughts that are related to depressed
  moods. Teaching the client the skill to challenge
  these negative automatic thoughts, by examining the
  evidence for, and against these thoughts. This leads
  to the client gaining new skills which includes
  reframing the negative thoughts to more reasonable
  and realistic alternative thoughts. This has a positive
  impact on the clients low mood
 Measuring outcome by rescoring the intensity of the
  client’s depressive moods to, establish validity of
 Design and implementation of experiments with
  client to test new beliefs.

         Preparing client for leaving counselling and
           maintaining newly learnt skills

From this initial work with clients, it may become apparent that
some progress has been made reframing the client’s negative
automatic thoughts, and alleviating the client’s depressed mood.
However Beck (1989, p. 181 ) proposes that “to understand
more fully why people behave as they do, we have to look deep
beneath their actions, beyond their automatic thoughts, and
ferret out their basic beliefs.” Core beliefs or schema are
defined by Gilbert (2007, p.212) as “basic organising systems
for knowledge about the self and others. These are built up
through life as the result of interpersonal experiences”. So
another therapy in this second generation is Schema Therapy,
which was founded by Jeffrey E. Young. in 1990. Described as
an integrative approach for longer term disorders, such as
personality disorder which are often associated with depression,
and treatment- resistant clients (Young et al.2003) It blends
aspects of CBT, Attachment, Gestalt, Objects relations,
constructivist, and Psychoanalytic schools “into a rich unifying
treatment mode”. (Young et al. 2003 p.1). This model sees
clients as having emotional needs, such as, (Stanley 2009)

1.Secure attachment to others. (includes safety, stability,
Nurturance, and acceptance)

 2. Autonomy, competence and sense of identity .
 3. Freedom to express valid needs and emotions
 4. Spontaneity and play
 5. Realistic limits and self control

 Young et al (2003, p. 10) states,

 “ a psychological healthy individual is one who can adaptively
 meet these core emotional needs…..the goal of schema therapy
 is to help patients find adaptive ways to meet their core
 emotional needs”

 However early childhood experiences and the child’s emotional
 temperament can interact to form maladaptive schemas, which
 Young et al ( 2003, pp.13-21) group into five categories of
 unmet emotional need, termed domains, that detail as follows:

i. Disconnection and Rejection: Clients with schemas in this
   domain are unable to form secure, satisfying attachments to
   others. They believe their needs for stability, safety,
   nurturance, love, and belonging will not be met.
ii. Impaired autonomy and performance: The ability to separate
   from ones family and to function independently, comparable to
   people of one’s age .Clients with Schemas in this domain, have
   expectations about themselves and the world that interferes

    with their ability to differentiate themselves, from parent
    figures and function independently.
iii. Impaired Limits: Clients with schemas in this domain have not
    developed adequate internal limits in regard to reciprocity or
    self discipline. They may have difficulty respecting the rights
    of others, cooperating, keeping commitments, or meeting long
    term goals.
iv. Other Directedness: Client in this domain place an excessive
    emphasis on meeting the needs of others, rather than their own
    needs. They do this in order to gain approval, maintain
    emotional connection, or avoid retaliation.
v. Over vigilance and Inhibition: clients in this domain suppress
    their spontaneous feelings and impulses. They often strive to
    meet rigid internalized rules about their own performance at
    the expense of happiness, self-expression, relaxation, close
    relationships, or good health.
  So in the assessment phase clients are helped to identify their
  schemas, to understand their origins, and the internal and
  external behaviours that perpetuate them. “Patient’s learn to
  recognise their maladaptive coping styles (surrender,
  avoidance, and overcompensation) and to see how their coping
  responses serve to perpetuate their schemas.”(Young et al 2003
  p.44) Assessment has many aspects including life history, self
  monitoring, and schema questionnaire, which helps identify how
  relevant the various schemas are to a client’s life. But Gilbert

cautions (2007,p.213) “they should not be used to imply there is
some negative schema sitting inside an individual…..schema are
about the way in which emotions and thoughts are organised
and patterned around certain themes”. The assessment phase
concludes with a schema focused case conceptualization. The
Change phase includes: Stanley (2009)

   Cognitive techniques where the schema driven cognitive
     distortions are challenged
   Interpersonal techniques which highlight the client’s
     interactions with other people so that the role of the
     schemas can be exposed.
   Behavioural techniques, where the therapist assists the
     client in changing long- term behaviour patterns.
  Additionally Hayes et al (2003, p .110) propose experiential
  techniques “to trigger the emotions connected to early
  maladaptive schemas and to re-parent the patient in order to
  heal these emotions and partially meet the patient’s unmet
  childhood needs”
Subsequently CBT became the parent of a new child in this
lineage of therapies. One influenced by eastern philosophy.
Particularly the experiential approach of mindfulness.

Third Generation: Mindfulness based strategies, MBCT,
and ACT.
Two third generation therapies Mindfulness Based Cognitive
Therapy, (MBCT) and Acceptance and Commitment Therapy
(ACT) incorporate the experiential approach of mindfulness.
“Mindfulness training is central to MBCT; it is also features, in
other interventions designated by Hayes as part of the third
wave of behaviour therapies such as ACT”. (Segal et al 2004,
p.55) Mindfulness is defined By John Kabat Zinn, (2008) as,
paying attention in a particular way: on purpose, in the present
moment, and non-judgementally. Mindfulness involves moving
from a doing goal orientated existence, into a being mode. It
allows us to be more in touch with our being, through a
systematic process of self observation, moment by moment, by
simply witnessing, what is happening for us in the present,
without trying to change anything. Shapiro’s (2006) model of
mindfulness helps to focus on the psychological mechanisms
that underline mindfulness based interventions. She proposes
three axioms that are not linear, but a dynamic cyclical process,
where interwoven aspects occur simultaneously. So that
mindfulness, is this moment to moment process that includes
these three axioms, as shown in figure 3, below:

Figure 3.Shapiro’s three Axioms of Mindfulness



Therefore mindfulness involves the intention, of paying
attention, to internal and external experience, with an attitude,
that is non- striving, and non- judgemental, indeed an
openhearted welcoming acceptance. Shapiro equates these three
axioms, as the internal behaviours involved in mindfulness,
which she proposes can lead to a shift for the individual, which
she terms re-perceiving. Subsequently Segal et al, (2004, p. 47)

   1. “What is the nature of cognitive vulnerability to relapse in
       formerly depressed patients ?

  2. “How does cognitive therapy reduce this vulnerability?

Questioning the prevailing view was that CBT achieved this, as
a result of specific effects in reducing dysfunctional attitudes,
Segal et al (2002 p. 38) state “this hypothesis received little
empirical support”. Instead of changes in the content of
depressive thinking, being the pathway to change, their own
“more detailed theoretical analysis suggested an alternative
possibility” (Segal et al 2004, p. 51) They proposed that CBT,
also leads to changes in how patients relate to their negative
thoughts and feelings, this shift in perspective, involves patients
in viewing them as passing mental events, in the mind that are
not necessarily valid. The Buddhist influence on this approach
can be seen in the words of the 14th Century Tibetan master
Longchenpa when he says “in the same way as at noon in the
hot season there appears on a plain the water in a mirage, so
also by the power of habituation to a belief in the mind as self
the mistaken presence of the fictions (about the world) comes
like a Mirage ” (1976, p. 72 )The Role of habitual negative
thinking patterns in clients who relapse into depression was
recognised by Teasdale et al (2002) However they identified
that CBT also involves a process of de-centering or distancing.
This they declared may be a long term benefit of CBT that
teaches clients to initiate this process when facing future stress.

Based on this they developed the model shown below as the
conceptual model underlying the development of MCBT.

Figure 4. Segal et al (2002) conceptual model underlying the development of MBCT for
prevention in recurrent major depression

                                                                 NO RELAPSE
Negative        Non- Negative thinking            POTENTIAL            Negative
Thinking        REMISSION                         RELAPSE            Thinking Patterns
EPISODE                                                              Nipped in the Bud

                                                  Low mood
                                           Reactivation of
                                           Negative Thinking
                                                                     Thinking Patterns

Accordingly Teasdale et al (2002) developed from Jon Kabbat
Zinn’s MBSR programme -which was generic to presenting
issues- an MBCT approach which was targeted specifically at
the prevention of relapse in recurrent major depression.
Significantly it involves clients developing conscious
awareness, rather than changing the content of mind. Teasdale et
al state (2004, p 53.) “It is not just what is processed that

determines whether relapse ensues, but how that material is
processed.” Mindfulness they see as an alternative cognitive
mode, and it has the added advantage of being an alternative to
experiential avoidance. Their eight week programme shadows
that of MBSR, which follows closely the Buddha’s Sutra on the
application of mindfulness. ( Kabat Zinn, 2009)
MBCT interventions gives clients the ability to “Disengage
from mind states characterised by self- perpetuating patterns of
ruminative, negative thoughts” (Teasdale et al 2002, p. 76) The
core skills must be learnt experientially by the client. Jon
Kabbat Zinn’s (2009) recent statement that the teacher /
therapist’s training of clients, must be based on the therapist’s
own daily experiential practice of mindfulness, presents a
challenge. It remains to be seen if therapists involved in these
third wave strategies, will accept this challenge.

Acceptance rather than change is a major component of
Acceptance and Commitment Therapy Founded by Steven
Hayes in the 1980’s. Called ACT it was originally known as
“Comprehensive distancing” (Zettle R.D.2007) Hayes et al
(2009, P.22) say that ACT

“Is a modern behavioural psychotherapy based on behavioural
principles and RFT, which used mindfulness process and

behaviour change process to establish greater psychological

Additionally they say that mindfulness has only recently being
examined through the lens of western science. ACT shows how
a modern approach to language and cognition, refines the
process of mindfulness and expands it applicability to having a
place in modern psychology. The four mindful aspects which
ACT for depression incorporates are
    Self as context
    Defusion
    Acceptance
    Contact with the present moment
   In this approach these four mindful aspects are combined
   with two other aspects of ACT that have a positive effect,
   particularly for clients who’s depression is an obstacle to
   them fulfilling their life goals.

    Values. ACT initially helps clients to identify values, by
      challenging them regarding what they want from life.
    Committed Action. Empowers clients to identify short and
      long term goals, and enables them to develop flexibility in
      moving towards them in a course of Committed Action.
      (Hayes et al, 2009)

ACT looks at mindfulness from the point of view of Relational
Frame Theory (RFT). RFT “fundamentally holds that human
language and cognition are based on relational frames” (Zettle
2007, p 10) Furthermore Zettle (2007, p. 11) sees “the ultimate
goal of ACT in working with clients with depression, is not to
eliminate their depression. Rather it is the promotion of
psychological Flexibility.” The six processes that ACT
observes as fostering psychological flexibility are, (Hayes et al
  1. Acceptance is a moment by moment process of actively
     embracing the private events evoked in the moment,
     without unnecessary attempts to change their frequency or
  2. Cognitive Defusion techniques are deigned to change the
     functions of private experiences, even when they have the
     same form, frequency, or situational sensitivity.
  3. Contact with the present moment, involves shifting
     attention to what is happening here and now.
  4. Self as context, Human language leads to a sense of self as
     locus or perspective, which cannot itself be fully
     experienced as a thing, since it is at the core of
     consciousness itself. Thus the self as context has always
     been present, transcending roles, thoughts , emotions, and
     experiences of the body

5. Values are life directions, not objects to be attained but
  directions that integrate ongoing patterns of purposive
6. Committed Action, involves behavioural changes that
  move the client towards value-consistent goals.
ACT sees the opposites of these core processes as “the core
pathogenic processes that support depression through their
contributions to the ‘dark side ‘of language.” (Zettle 2007, p.
Accordingly in fostering change to these processes;

   Fusion; where negative self evaluation is bought into is
      countered by defusion which expands a behavioural
      repertoire by responding in an alternative manner to
      fused material” (Zettle 2007, p.14)
   Experiential avoidance; involves one of the main ideas
      in ACT Dirty pain, the emotional distress that results
      from unsuccessful attempts to control psychological
      experiences. This is countered by Acceptance, which
      involves the willingness to actively choose to
      experience unwanted psychological events, without
      trying to control them.
   Rumination; the process of living in fusion with a
      verbally constructed past or future, rather than

        functioning psychologically in the here and now is
        countered by Contact with the Present Moment.
      Rigid negative conceptualizations about the self in
        depression; are countered by fostering a more flexible
        sense of self as context through “disputational
        strategies and/or behavioural homework.” (Zettle 2007,
        p. 15)
      ACT expands the understanding of Mindfulness from a
     western perspective. It moves away from the realm of
     meditation, by developing a new creative repertoire of
     experiential exercises, which enhance psychological
     flexibility. For the depressed client this amounts to an
     alternative mode of relating to contents of the mind, while
     also strengthening the client’s commitment to a life
     consistent with their values

Third generation strategies expand the behavioural approach to a
degree that would seem unrecognisable to B.F Skinner.
However Shakyamuni Buddha might be more at home with
these developments, as Gilbert proposes “the Buddha’s great
insight was that the mind needs to be trained to understand the
power of the threat system, and self- identities forming systems,
for they will easily take control of our minds ( as they are
evolved to do) ( 2005, p. 64) This concurs with Hayes view that

thinking causes pain, when he says (2005, P.59 ) “the two
biggest buttons are the process of evaluation and self-
conceptualisation. Thoughts …create pain in two ways : they
bring painful events to mind , and they amplify the impact of
mind through cognitive fusion that leads to avoidance”
To-days new third generation CBT interventions, that
incorporate mindfulness, have an important role to play in
relieving human suffering, just as the traditions which inspired
their new directions, have been doing for millennia.


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