A Theory Based Evaluation of Cognitive Behavioural Therapy

The purpose of this essay is to provide a theory based evaluation of Cognitive Behavioural Therapy (CBT). The first part of this essay will concentrate on defining CBT including a brief description of its derived history and the therapies that have contributed to its development. I will then move on to review the tools used in the four step process of CBT (assessment, formulation, intervention and evaluation). I will also incorporate how my learning of theoretical concepts relates to my work based practice.

Cognitive Behavioural Therapy is a psychotherapeutic approach that aims to solve problems concerning with dysfunctional emotions, behaviours and thinking (cognitions) through a goal-orientated, systematic procedure. According to Craddy, CBT helps clients to change their behaviour and their thinking patterns. He states that clients can learn to ‘tolerate unpleasant feelings and discover that they are likely to diminish with time…they can be persuaded that avoiding experiences of any level of anxiety in the short term is not necessarily advantageous to their mental health’ (Craddy, 2006 p.28). CBT is a brief and time limited therapy which is highly effective for a number of disorders including phobias, anxiety, depression, eating disorders, drug or alcohol problems and sleeping disorders.

From the 1970’s CBT became politically appealing in the United Kingdom. At that time there was a large number of the population being in receipt of sickness benefits and on medication causing a financial burden on the economy. The Government’s aim was therefore to address these issues by using CBT. This therapy suited the political agenda as CBT was cost effective, measurable and was a short term intervention particularly when compared to other therapies. However, it is important to recognise that CBT does not meet the needs of all individuals and will therefore not always be effective. Other types of therapy should not be dismissed. In addition to this, CBT has been criticised as being a ‘simple minded “cookbook” approach to therapy: if the client has this problem, then use that technique’ (Westbrook et al, 2011,p1). Very often, CBT clients will return to a CBT therapist a number of years later after it was first received. This can therefore raise the question, how effective was this therapy the first time it was accessed?

CBT was developed through the merging of two therapies, Behaviour Therapy and Cognitive Therapy. I will not go on to discuss Behaviour therapy in more detail.

Behaviour Therapy developed in the early 20th Century with its three distinct points of origins in South Africa (Wolpe), United States (Skinner) and the United Kingdom (Rachman & Eysenck). Behaviour Therapy is based on learning theory which aims to treat the client through techniques designed to reinforce desired and eliminate undesired behaviours (McGuire, 2000). Classical and Operant Conditioning are seen as the primary theories of learning. Classical conditioning (Pavlov) is described as learning that is achieved through association, for example a fear of the dentist maybe associated with the feeling of discomfort and pain. Operant conditioning (Skinner) is described as a process of learning responses through positive and negative reinforcements. Skinner describes positive reinforcement as rewards which are given every time a correct response is given to a stimulus e.g. affection may be given as a ‘reward’ to a child. That child will repeat that behaviour to endeavour to gain that affection again. Negative reinforcement is described as the removal of the unpleasant stimulus once the correct response has been elicited. In other words, negative reinforcement is if something such as pain that is relieved through painkillers is removed from us, we would reach for the painkillers again if the pain returned. According to Skinner, both positive and negative reinforcements strengthen our behaviours but punishment weakens it.

It is important to acknowledge that conditioning can sometimes be imposed upon us without us realising. The media for example could do this through advertising. This could be particularly damaging for vulnerable and young individuals, for example they may believe that they must look or behave in a certain way which could be damaging to themselves and/or society (e.g. youths – ‘hoodies’, anorexic – loose more weight).

Although it has been argued that the early work of behavioural approaches were successful in treating many neurotic disorders, they had little success in treating depression (Clark et al 1997). Whereas behaviour therapy sees behaviour as learnt which can therefore be unlearned, in contrast the psychodynamic approach sees behaviour to be governed by repressed unconscious thought and by the ego’s attempt to deal with psychic conflicts which is caused by day to day life. Person Centred Therapy sees human behaviour to be ‘motivated by an innate drive towards growth and wholeness. Disturbed behaviour is seen as an indication that growth is blocked either through lack of awareness or distorted perception, or both’ (Hough, 2002, p158). It would appear that Behaviour Therapy does not allow time for growth, which in turn leads to the client’s lack of deeper understanding into their problems.

I will now go on to discuss Cognitive Therapy. Beck’s model of Cognitive Therapy is agued to be one of the most influential CBT models (Wills, 2006). It was in the 1960’s that he developed his approach which became best known for its effective treatment of depression. According to Wills, Beck’s model suggests, ‘there are specific cognitive profiles of thoughts and beliefs that typically accompany problem areas such as depression & anxiety. Once these profiles have been formulated, therapist and client engage in a collaborative, empirical process to test out these thoughts and beliefs and their accompanying emotions and behaviours to promote enduring therapeutic change’ (Wills, 2006, p11). In other works, Cognitive Therapy aims to help the client overcome difficulties by identifying and changing dysfunctional/distorted thinking, behaviour and emotional responses. This involves developing skills to change beliefs and behaviour, recognise distorted thinking and to relate to others in different ways. (McGuire 2000). Beck’s work was strongly influenced by Ellis’ Rational Emotive Therapy (later known as Rational Emotive Behavioural Therapy). The philosophic origins of Ellis’ therapy go back to the Stoic philosophers (Epictetus & Marcus Aurelius) for example, Epictetus wrote ‘Men are disturbed not by things, but by the view which they take of them’ (cited in Westbrook et al, 2011, p5)’.

Cognitive Therapy is an educative therapy which aims to teach the client to be their own therapist. By doing this, it can teach the client to identify, evaluate and respond to their distorted thoughts and beliefs. It aims to be time limited and its sessions are structured. This type of therapy has been very effective for a lot of clients particularly with those suffering with depression. However, Cognitive therapy has been criticised as being a superficial and mechanistic approach (Sloan, 1997). Furthermore, Genova states Cognitive Therapy ‘does not reflect current knowledge of how the brain works’, ‘it is not rational’ and ‘it gives patients no means of responding to unsolvable problems: to the inherently tragic nature of life’ (Genova, 2003, p2).

To summarise, the integration of Behaviour and Cognitive Therapies became know as Cognitive Behavioural Therapy. As previously mentioned, Beck’s model is one of the most influential CBT models (Wills 2006, Westbrook et al 2011). Others include Ellis’ Rational Emotive Therapy, Meichenbaum’s stress inoculation therapy (SIT) and Young’s schemas-focused therapy (McGuire, 2000).

The next section of this essay will concentrate of discussing the four step process of CBT (assessment, formulation, intervention and evaluation) and the tools that can be used in each process. I will also incorporate how my learning of theoretical concepts relates to my work based practice.

The first stage used by the therapist in CBT is the assessment process. The purpose of this stage is to establish a starting point (or base line) to assist both parties to recognise and agree where the client is. They also need to reach a shared agreement of what the problem is. Westbrook et al suggest that in the this stage, ‘the therapist is constantly trying to make sense of the information coming from the client and building up tentative ideas about what process might be important in the formulation’ (2011, p67). In addition to this, the assessment process allows for information to be recorded which enables the therapist to make comparisons and evaluations about the client’s change during and at the conclusion of therapy. This is particularly important as it provides evidence for measurement which in turn can affect funding for organisations. In my previous employment as a Probation Officer, I can identify this stage in relation to offending behavioural group work programmes which were underpinned by CBT or REBT. Comparisons and evaluations were done via pre and post psychometric testing (questionnaires). Another key component in the assessment stage is the therapeutic working alliance between the therapist and client. This is essential in being able to communicate and challenge in a mutually trusting and respecting way.

Tools which can be used in the assessment stage will include skills that the therapist may already possess as a result of training and experience such as active listening skills and story telling. These tools allow for the client to open up and can avoid misunderstanding. Nadig regards active listing skills as imperative in all interaction. He states ‘we are given two ears but only one mouth, because listening is twice as hard as talking’ (Nadig, 1999). I can see the relevance of active listening skills and believe that I use this skill in all aspects of my personal and working life. I am aware for example that I will reflect back what my client or team member has said to ensure that I have not misunderstood or misheard what they have said.

Other tools which are used by the therapist are FIDO (Frequency, Intensity, Duration and Onset) and BASIC ID (Behaviour, Affect, Sensations, Image, Cognitions, Interpersonal & Drugs). FIDO is used specifically to explore how often, how bad and how long the issue has been a problem as well as finding out when it first began. With regards to BASIC ID, I understand that this gives the therapist a clear and concise indication of the problems that are occurring (including cognitions and behaviour). These tools have been, and will continue to be incorporated into my role as a line manager particularly during supervision sessions and when I work with clients. I have found that they have both allowed me to gain focus and have a better understanding of the problem. However, I am aware that if my relationship with a client or team member was not good, then perhaps they may not respond to these tools.

After the assessment stage, is formulation. According to Simmons et al, formulation ‘provides the overall picture of the development and maintenance of the client’s problems. It enables the therapist to develop an understanding and individualised treatment plan based on the cognitive-behavioural model of psychological distress’ (p.64). In other words, it is a blueprint to help the therapist and the client figure out what is going on. Formulation needs to be collaborative, holistically approached, simple, logical, clear and helpful in terms of what to do next with the client. A formulation is not a diagnosis. It is an agreement. In terms of work based practice, I have used the formulation stage during supervision with one of my team members. After completing the assessment stage, together we were able to put in place an action plan to move forward in addressing her anxiety which resulted in poor performance when facilitating ‘Family Group Meetings’ (action plan included: she would observe other colleagues, reflective logs and complete a thought record). I found that this way of working embowered the individual and she felt supported.

Intervention is the third stage used in CBT. This is where you implement the action plan by the active participation of the client (and therapist if needed), skilfully using a range of cognitive and/or behavioural methods to teach them in the acquisition of improved skills in their use of more adaptive cognitive, behavioural and physiologically responsive strategies for the alleviation of distress and development of personal effectiveness. (McGuire, 2000). Interventions can include role play, thought record, relaxation and mastery & pleasure chart. These can be used and completed together or set as homework for the client. If in agreement, the therapist can contact the client for an update on their homework. A benefit of homework tasks can ensure that the sessions remain on track in being a brief and time limited therapy. It also allows the client to put their learning into practice outside of the therapy room. In terms of role as a Family Meeting Co-ordinator, I have implemented this stage a lot with my clients who experience anxiety in attending a Family Group Meeting.

After collaborative discussion, the client has a viewing of the venue/room of where the meeting will take place. In addition to this, seating arrangements, exit routes and advocates are agreed. I have also used thought records in supervision which has allowed my team member to record the situation, thoughts and feelings which have impacted on their behaviour. They have them disputed the distorted thoughts and replaced them with rational/healthy ones. In terms of relaxation, I have used this as part of the anger management course when I was a probation officer. For a number of offenders, this method worked really well in helping them to unwind and to finally recognise tension which they had previously failed to notice. I’m also aware that relaxation techniques do not work for all individuals. Again, some offenders who were subject to this often reported feeling higher levels of anger compared to before using this technique.

The final stage is Evaluation. This is an important stage for two reasons. Firstly, it allows the therapist to evaluate the client’s change. This could be done by comparing the same ‘tools’ used in assessment that can also be used at the conclusion of therapy (e.g. questionnaires, anger record, statement cards, psychometrics). This stage can be particularly important for organisations if their funding is target/outcome driven. Secondly, it acknowledges the new skills that the client has learnt to address their problems. The intended purpose of this is to empower the individual to continue accessing these new skills whenever they are need in the future.

To conclude, this essay has provided a theory based evaluation of Cognitive Behavioural Therapy (CBT). I began by defining CBT which included a brief description of its derived history and the therapies that contributed to its development. I then went on to review the tools used in the four step process of CBT (assessment, formulation, intervention and evaluation) and I incorporated how my learning of theoretical concepts related to my work based practice. Applying my learning of CBT to my work base practice has been invaluable particularly the tools that can be used (e.g. FIDO & BASIC ID).

I am fully aware that CBT is structured, time limited, measurable and directive compared to Person Centred Therapy which is non–directive and believes the client has his or her own answers. I am also aware of the Transactional Analysis approach which can be particularly useful for clients struggling with relationships. Overall, I believe that there is no stand alone therapy that offers better results than the other – they all have their strengths and weaknesses. The effectiveness of any therapy could be attributed to the fact that individual respond to therapy in different ways. In other words, what works for one individual may not for another.

REFERENCES/BIBLIOGRAPY:

1. British Association of Behavioural & Cognitive Psychotherapies – www.babcp.org.uk

2. Clarkc D, Fairburn, CG & Gelder, MG. (1997). Science & practice of CBT, Oxford, Oxford University Press

3. Craddy, C (2006). A Place for CBT…and CBT in its Place in Therapy Today – December 2006

4. Genova, P (2003). Cognitive Therapy’s Faulty Schema in Psychiatric Times, October 2003

5. Hough, M (2002). A Practical Approach to Counselling, London, Pearson Education Limited

6. Martinsen, EW, Olsen T & Tonset E (1998). Cognitive Behavioural Group therapy for Panic Disorder in the general clinical setting, New York, McGraw-Hill

7. McGuire, J (2000). Cognitive Behavioural Approaches, Liverpool, Home Office

8. Nadig, L.A (1999). Tips on Active Listening – publisher unknown

9. Rachman, S (1997). The evolution of CBT.

10. Simmons, J & Griffiths, R (2009). CBT for Beginners, London, Sage

11. Sloan, G. (1997). Beck’s Cognitive Therapy: a critical analysis in British Journal of community Nursing, Vol.2, Iss. 10, 10 November 1997, pp 460 – 465

12. Westbrook D, Kennerley H & Kirk, J (2011). An introduction to Cognitive Behaviour therapy: Skills & Applications (2nd Edition), London, Sage.

13. Wills, F (2006). Delivering CBT in Therapy Today – June 2006