To understand Cognitive Behavioural Therapy (CBT) better, we must be aware of it’s origins and how it has evolved over the years from different schools of thought. It’s foundations can be found back in the early part of the 20th century with the work of Pavlov and other Russian researchers and later with Joseph Wolpe who developed Behavioral Therapy (BT). This was seen as a challenge to Freud’s Psychodynamic Approach and Wolpe found how BT could be measured as opposed to Freud’s approach which could not provide empirical evidence.
Cognitive Therapy (CT) was developed by Aaron Beck, an American psychiatrist and psychotherapist at the University of Pennsylvania in the early 1960’s. His initial work focused on research into depression and how it could be treated. Beck’s work included the theory that faulty or dysfunctional assumptions are laid down as cognitive schemata in childhood and later are activated by critical happenings in adult life. This joining of events and dysfunctional assumptions bring about what Beck was the first to describe as `negative automatic thoughts` (NATs) which he believed was at the root of depression. Negative automatic thoughts are a key concept of CBT, which are negatively tinged appraisals or interpretations – meanings we take from what happens around us or within us. This breakthrough came when Beck observed a link between his patient’s `self talk` and their feelings. He also used the term `hot thoughts` interchangeably with `automatic thoughts` to describe thoughts heavy with negative emotions. As we know Beck’s method became known as cognitive therapy, referring to the key role played by thoughts and beliefs in producing feelings.
REBT – pronounced R.E.B.T.
As previously mentioned previously Cognitive Behavioural Theory evolved from different schools of thought and encompasses also the work of Dr Albert Ellis a New York clinical psychologist who developed Rational Emotive Behaviour Therapy (REBT) in 1955. Originally working as a psychoanalyst he later became dissatisfied with this kind of therapy and labelled it `inefficient` because it did not produce very effective results.
Ellis spoke of `thought-feeling fusion` which meant that our cognitive and emotional responses are sometimes two aspects of the same thing. Ellis is famous for quoting a the first-century philosopher Epictetus who said `Men are disturbed not by things but by the views which they take of them` Later Shakespeare makes Hamlet say `There is nothing either good or bad, but thinking makes it so, to me it is a prison. During the mid 60’s and 70’s the influence of REBT continued to spread with the writings and presentations of Ellis for both professional and lay audiences and the general area of cognitive behavioural therapy gained prominence and respectability.
Within REBT is the premise that humans are happiest when they have set themselves important life goals and work towards achieving them. Linked directly to this is the REBT definitions of `rational` as `that which helps people to achieve their basic goals and purposes` and `irrational` as `that which prevents them from achieving these goals and purposes`. Here we see strong connections to Humanistic Psychology and the work of Maslow and his `Hierarchy of Needs` where humans work towards `self actualisation` - a reaching of one’s full potential.
The ABC model
A major aspect to Ellis’s REBT model is the idea that our reaction to having our goals blocked or the thought of having them blocked is determined by our beliefs. To show this, Ellis developed what we know as his ABC model which helps people to see how their beliefs cause their emotional and behavioural responses
The ABC model
A. Something happens. (Activating event)
B. You have a belief about the situation. (Belief)
C. You have an emotional reaction to the belief (Consequence – emotional and behavioural)
An example of this might be:
A. An acquaintance sits on a different table from me in the local coffee shop
B. I believe I’m not liked by this person and she doesn’t want to sit with me.
C. I feel hurt and angry
The ABC model shows that A does not cause C. It is B that causes C i.e. If my belief (B) was different e.g. she didn’t see me, or she wants some quiet time, then my emotional response (C) would be different.
According to Ellis there are `Three Basic Musts` these are:
- I must do well and win the approval of others or else I’m no good.
- Other people must treat me considerately, fairly and kindly and exactly the way I want to be treated. If they don’t, they are no good and they deserve to be condemned/punished.
- I must get what I want, when I want it, and I must not get what I don’t want. It’s terrible if I don’t get what I want and I can’t stand it.
These rigid and absolute beliefs can lead to psychological problems which include:
- Depression, shame and guilt for the first
- Rage, passive aggression and acts of violence for the second
- Self pity and procrastination for the third
- Ellis in his REBT work defined some of the characteristics of irrational thinking such as:
- Repetition – recurring irrational belief.
- Misattribution – blaming of ourselves/others/events, leading to distress.
- Anti-Proof – un-provable beliefs.
- Over Generalising – sweeping statements.
- Demanding – `musts, shoulds and oughts are typical of demands.
- Self rating – unrealistic self evaluating.
- Awfulising or Catastrophising - imagining all sorts of disasters resulting from that one small event.
Merging of Schools
Gradually through time the two schools of CT and REBT merged and CBT became an approach in it’s own right. Since then CBT has been applied to a number of problems such as anxiety, phobias, substance abuse, schizophrenia, OCD, post traumatic stress disorder, bipolar disorder and couples work. Today we see many other branches of CBT such as Schema-focused therapy, Mindfulness-based CBT (MBCBT) Acceptance and Commitment therapy (ACT) and CBT Hypnotherapy.
A key difference between REBT and CBT is `secondary disturbance` and this is where somebody has a negative emotional response to their emotional response. For example in CBT we might have the belief of `I’m a failure` whereas in REBT the belief would have another layer to it, as in `I’m a failure and I can’t stand it`.
To help us analyses the therapeutic process of CB theory it’s useful to highlight that it’s fundamentally a collaborative project between the practitioner and client and both participate actively. The therapist knows about effective ways to help with problems and the client is an expert in his own concerns and issues. Keeping in mind that the client may be new to therapy or the collaborative emphasis is not what the client expected, clarification of the client’s expectations and why they are there is helpful. As CBT is structured and problem focused, the therapist works with the client to set an agenda and attempt to abide by it. CBT is educative and this may involve the therapist talking more than in some other therapies and will call for the client engaging in between session tasks called `homework`. From my own experience those clients who connect with CBT do so because of the empowerment they feel from being able to help themselves by acquiring a skill that they can use between sessions in times of distress or to stay psychologically stable.
CBT is said to help the client to think less negatively, so that instead of feeling hopeless and depressed, they can cope better with and even start to enjoy the situations they face. CBT includes goals the client might like to set and tasks between sessions, called `homework`. Also CBT deals with current situations more than events in the clients past or childhood and research shows that it works for a variety of mental health problems. However this doesn't mean that it's better than other therapies, but simply that others may not have been studied as much.
In particular CBT can help with:
- Panic Attacks
- Obsessive Compulsive Disorder (OCD)
- Post Traumatic Stress Disorder
- Some eating disorders
The following case study relates to a past client of mine. It is anonymous and certain facts have been changed or omitted to maintain confidentiality.
If we consider the contribution of the CB theory model to therapeutic practice, I find it useful to relate it to my own Integrative work and the way CB Theory plays it’s part in treating the client as a whole. An example of this is a health professional that came to me because of stress problems at her busy workplace. Using CBT methods we (because it is collaborative) established that it was not the activating event of being a busy health worker that was causing distress but her beliefs that she was not good enough at her work and that the college she had attended was full of `upper-class types`. Once we discovered her beliefs and looked at the emotions that were caused, we worked on ascertaining if there was actually any evidence that she was not good enough. The belief about college was harder to explore but revolved around her working class childhood and her original unskilled work on leaving school. CBT methods brought to the surface not only many of her insecurities and feelings of being out of her depth but also a desperate need to `make good`.
As with any Psychological approach, CBT has strengths and limitations. We know it is affective for a wide range of problems and this is supported by well documented research. CBT is offered widely by the NHS here in the UK generally within Primary Care where 6-15 sessions might be obtainable. CBT is sometimes labelled as a `quick fix` or a `sticking plaster` and is regarded as time limited therapy, where a suspicion of CBT `wearing off` still exists and with it a belief that it may need `topping up` or refreshing at a later date.
As with all therapies CBT needs the client’s co-operation to some degree. In my own practice I remember one client where the process was impeded by their attitude and aggression, which led me to believe CBT was not for everyone. Their presenting issue was anger and they would arrive straight from work in a dirty and unkempt fashion with muddy wellington boots and sit with arms folded glaring at me and ordered that I `cure` them. Although obviously intelligent and resourceful, they were resistant to therapy and their aggression made interaction difficult.
Being a collaborative approach the client may well benefit from the knowledge that they are helping them self and this will fit in well with the idea of responsibility to one’s self and the notion that for every action there is a consequence. However in our multi-cultural society we might see some elements of it in which one’s own responsibility, choices or options are withheld or denied. This might be because of culture, gender or politics and here we might find CBT and it’s premise that there is always another way of looking at things difficult to work with.
In conclusion I believe that we can see clearly how Cognitive Behavioural Therapy as an approach has evolved over the years and continues to do so. From it’s foundations by Pavlov and Wolpe, through the years of Beck and Ellis to where it is now as one of the most extensively researched methods available, we see the forming of structure and progress. Today we see not only CBT being widely offered as a pure approach but also being integrated into therapist’s work to help with a huge raft of issues. I lean towards the notion that in another ten years or so, therapists will be writing of a number of new applications for this popular method.