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Cognitive Behavioural Therapy

Cognitive Behavioural Therapy (CBT) has been developed and further refined to sit as the most widely used psychotherapy in initially, the treatment of depression and anxiety, and extending to the treatment of a range of mental health issues (Wright, 2006).

 Background

Cognitive Behavioural Therapy, was developed by Aaron Beck, and colleagues during the mid 1960’s (Luty et al, 2010; Wright, Thase & Beck 2008). Initially drawing on Greek and Eastern philosophies that identified a link between internal ideas impacting on emotions, and incorporating the neo Freudian concepts of self perception and conscious experience, with later influence via behaviour therapy (Wright et al. 2008). The culminating elements of influence form the fundamental CBT concept that links cognitions and behaviours to outcomes, “cognitive processes can influence behaviour, and behaviour can influence cognitions.” (Wright, 2006:173).

Principles

The link between cognitions and behaviour allows the therapist to engage at either level.

Cognition

Conscious thoughts – rational.

Automatic thoughts – not subject to rational assessment.

Schemas – fundamental, shaped by personal development/life experiences.

Behaviours

  1. Depressive behaviours able to be modified
  2. Anxiety disorders respond to behavioural techniques
  3. Social, coping and problem solving capacity is improved by behavioural intervention.                                                                               (Wright, 2006:174).

Treatment

CBT is delivered within a framework of between 5 – 20 sessions with the diagnosis, severity of symptoms and the capacity to provide treatment determining factors; booster sessions can be utilised to maintain positive treatment gains (Luty et al. 2010; Wright et al. 2008). The focus of CBT is “primarily on the here – and – now, problem – solving, and utilising rationality and behavioural activation.” (Leahy,2008:770). The sessions are collaborative, with a ‘teamwork’ approach to discovery between therapist and clinician; they are educative, with the use of resources for education/self help provided. Homework for clients is a usual activity to continue the framework of psychoeducation as a key concept of treatment. (Turkington et al, 2002; Wright, 2006). Oakley makes the distinction between a ‘medical model’ role of doctor – patient, to the increased collaborative approach contained in a teacher – student relationship, the client playing a far more active role (2014:3).

Therapeutic relationship

The literature is strong in identifying the therapeutic relationship as paramount; “As in other effective psychotherapies, CBT also relies on the nonspecific elements of the therapeutic relationship, such as rapport, genuineness, understanding and empathy.” (Wright, 2006:175). Leahy’s paper on the therapeutic relationship in CBT, cites the empirical support evident through a review of the literature; the concept that the therapeutic relationship can be controlled and developed is clear; “The therapeutic tasks and the relationship in cognitive behavioral therapy differ from those in psychodynamic therapy.” (2008:770). The relationship is not viewed as a point of achievement, but as part of an ongoing process. Leahy’s paper explores the potential ‘shape’ of the relationship, of “negotiating the alliance” (2008:771), dependant on where the therapist/client sit within the cognitive/behavioural construct. Oakley (2014) identifies CBT as practiced in a collaborative, teacher – student based relationship where the focus is on the client developing the ability to self maintain and treat symptoms, through the learning environment.

Efficacy

The body of evidence in support of CBT as effective in the treatment of depression and anxiety, generalized anxiety and eating disorders, is strong (Joyce et al. 2007; Shelton & Hollon, 2012; Wright, 2006; Wright et al. 2008 & Borkovec et al. 2004).

Turkington et al (2002), in the treatment of schizophrenia, adapted CBT to a reduced number of six sessions over two to three months, delivered by community psychiatric nurses who had all received intensive training in CBT for a ten- day period. Results identified the successful application of standard CBT strategies to “achieve symptomatic improvement without increasing suicidality.” (and), “compatible with the results achieved when CBT was delivered by expert therapists.” (p.526). A more recent study identified CBT as emerging “as an effective adjuvant to antipsychotic medication in the treatment of schizophrenia. It should be considered as a component of a comprehensive treatment package along with antipsychotic medication.” (Rather et al. 2010:635).

The emergence of Dialectical Behavioural Therapy (DBT) over more recent times, as more effective in the management of borderline personality disorder, and suicidal behaviours (Burns & Nolen – Hoeksema, 1992; Wright, 2006), highlights the development of CBT as a ‘new wave’ behaviour therapy (Hayes, 2014).

Reference list

Borkovec, T.D., Newman, M.G., & Castonguay, L.G. (2004). Cognitive – Behavioural Therapy for Generalised Anxiety Disorder With Integrations From Interpersonal and Experiential Therapies. In, FOCUS, Vol. 2, No.3 July, 2004:392-401.

Burns, D.D. & Nolen – Hoeksema, S. (1992). Therapeutic Empathy and Recovery From Depression in Cognitive – Behavioral Therapy: A Structured Equation Model. in, Journal of Consulting and Clinical Psychology, 1992,Vol. 60, No.3:441-449.

Joyce, P. R., McKenzie, J.M., Carter, J. D., Luty, S. E., Frampton, C. M. A., & Mulder, R. T. (2007). Temperament, character and personality disorders as predictors of response to interpersonal therapy and cognitive behavioural therapy for depression. In British Journal of Psychiatry, 190:503-508

Leahy, R.L. (2008). The Therapeutic Relationship in Cognitive – Behavioural Therapy. In, Behavioural and Cognitive Psychotherapy, 2008, 36, 769-777.

Luty, S.E., Carter, J.D., McKenzie, J.M., Rae, A.M., Frampton, C,M.A., Mulder, R.T. & Joyce, P.R. (2010). Random Controlled Trial of Interpersonal Psychotherapy and Cognitive-behavioural Therapy for Depression. In, Focus, Winter 2010, Vol VIII, No.1

Oakley, M.E. (2014). What is Cognitive Therapy?, Center for Cognitive Therapy. http://www.cognitivetherapyla.com/CognitiveTherapy.php Article accessed 05.05.2014

Rathod, S., Kindon, D., Weiden, P. & Turkington, D. (2010). Cognitive – Behavioural Therapy for Medication Resistant Schizophrenia: A Review. In, FOCUS, Vol. 8, No. 4. pp. 626-637.

Shelton, R., & Hollon, S.D. (2012) The Lon-Term Management of Major Depressive Disorders. In, FOCUS focus.psychiatryonline.org  Fall 2012, VolX, No 4:434-441

Turkington, D., Kingdon, D. & Turner, T. (2002). Effectiveness of a brief cognitive behavioural therapy intervention in the treatment of schizophrenia. In, The British Journal of Psychiatry. 180: 523-527

Wright, J.H. & Davis, D. (1994). The Therapeutic Relationship in Cognitive – Behavioral Therapy: Patient Perceptions and Therapist Responses. In, Cognitive And Behavioural Practice 1, 25-45, 1994.