Cognitivebehavioural therapy CBT

CBT has become established as the psychotherapy of choice, being perceived as effective and cost-effective. It remains important to understand the twin strands of CBT. Behaviour therapy per se is now less prominent. However, cognitive therapists are happy to admit that their treatment involves components of behaviour therapy, such as activity scheduling, and that the term 'cognitive therapy' is effectively shorthand for CBT.

The principles of cognitive therapy and behavioural therapy will now be described, followed by an account of how they are brought together in CBT.

Cognitive therapy is based on the work of Aaron Beck. Like most American psychiatrists of his era, his training was psychodynamic. However, he became frustrated with the lack of progress of patients under his care, in relation to the amount of input. He thus sought to address practically and directly, rather than through the convolutions of psychoanalysis, the maladaptive beliefs and attitudes presumed to contribute to current symptoms.

Cognitive (Latin cogito: 'I think') therapy is based on the principle that thought influences mood, so that depression, anxiety, and other symptoms arise from, or are perpetuated by, faulty thought patterns and beliefs. The aim in therapy is to identify automatic negative thoughts that appear to be contributing to the symptoms, and to encourage the patient to reconsider them in the light of the evidence, and to try alternative viewpoints and behaviour patterns. This process should lead to better understanding of the symptoms, and more control over them. For some patients, exploration of visual images is an appropriate variant of this technique.

Beck originally described several types of maladaptive thinking patterns to be addressed in therapy, including the following:

• selective abstraction: dwelling on only the negative aspects of a situation

• overgeneralization: a single matter wrongly assumed to have wide-ranging implications

• magnification: a trivial matter exaggerated out of proportion

• all-or-none reasoning: issues seen as 'black or white' with no middle ground

• arbitrary inference: things assumed, without good evidence, to be negative.

Behaviour therapy is based on learning theory, a model of human and animal behaviour originating in the field of pure (non-clinical) psychology. In the 1950s, workers such as Eysenck, Lazarus, Wolpe, Bandura, Marks, and Rachman began to introduce these ideas into clinical practice as behaviour therapy. This involves the acquisition of desirable new behaviours as well as the loss of unwanted ones.

Behavioural therapy is a structured method, employing practical strategies to overcome current symptoms. The principle is changing behaviour, rather than addressing presumed underlying causes or accompanying thoughts and feelings. It is related to Pavlovian principles, in which external changes have significant effects on the responses of the individual.

Common parlance such as 'get back on the horse' or 'use makes master' encapsulate the principle that doing a feared activity or entering a feared situation of itself causes subsequent fears to be less. This illustrates the principle of behaviour therapy.

Behaviour therapy was originally applied to neurotic symptoms that could be regarded as 'maladaptive learned responses', as in monophobia (phobia restricted to one specific object or situation) developing after a frightening experience. Behavioural techniques have since been applied to a much wider range of disorders, including generalized anxiety states, obsessive-compulsive disorder, eating disorders, sexual problems, and the management of chronic disability caused by brain damage or schizophrenia.

Problems are defined and objectives of therapy agreed at the beginning. Progress during therapy is regularly assessed by measurable criteria: for example, frequency of occurrence of a particular behaviour pattern, or questionnaires to monitor mood change.

Critics have claimed on theoretical grounds that, because the past events or unconscious conflicts which produced the symptoms are ignored, behaviour therapy cannot produce a lasting cure, and that 'symptom substitution' will occur. In practice, this seldom happens.

Behaviour therapy appears comparable in efficacy to other forms of psychotherapy, it is often less time-consuming than other methods, and the patient need not be intelligent or verbally fluent to benefit. Specific techniques include the following:

• Systematic desensitization (graded exposure): progressive introduction to a feared object or situation, using an agreed hierarchy. For example, a person with a fear of spiders agrees with the therapist to encounter them first in imagination, then in pictures, and then as a plastic one, before finally seeing a real one.

• Flooding: immediate exposure to the feared stimulus in its full form. This is claimed to be as effective as graded exposure, but many patients find the prospect unacceptable.

• Modelling: the patient imitates the therapist's behaviour, for example, in social skills or assertiveness training.

Biofeedback techniques: to modify physiological variables such as heart rate, blood pressure, and muscle tension. Some people find this helpful in controlling anxiety or pain.

• Response prevention: for compulsive behaviour. For example, the therapist prevents the obsessional patient from repeated hand washing; the patient's anxiety initially rises, but then decays naturally when the feared consequence (such as infection) does not occur.

• Thought stopping: for obsessional thoughts. The patient learns to stop an obsessional train of thought, usually by 'switching' to another. This is very similar to the cognitive technique of 'distraction'.

• Massed practice (satiation): the unwanted behaviour is repeated so often that the patient no longer wants to continue it.

• Aversion therapy: traditional forms are now seldom used for ethical reasons. They involved coupling an unwanted behaviour, such as substance misuse or deviant sexuality, with an unpleasant stimulus such as drug-induced vomiting or electric shock. Milder self-administered forms may be helpful; for example, snapping an elastic band worn around the wrist can provide distraction from obsessional thoughts or from an unwanted behaviour such as overeating.

• Covert sensitization: aversion therapy carried out in imagination only.

• Shaping (chaining): the separate learning of each stage in a complex process; for example, a brain-damaged or learning-disabled patient learning to dress.

• Token economy regimes: rewards are given for desirable behaviour, and privileges withdrawn for undesirable behaviour. The approach has been used in the rehabilitation of chronic schizophrenics, but ethical considerations apply.

Relaxation training: used in a variety of problems, mainly to manage anxiety. The patient tenses up and then progressively relaxes all muscle groups, while breathing regularly and deeply. This is a gradually acquired skill, which can be taught individually or in groups, or with the aid of commercially available audio- and videotapes.

A course of behaviour therapy would typically involve several of the above components; for example, a spider phobic might take part in a programme of graded exposure, and be given relaxation training to cope with attendant anxiety. It seems likely that most behavioural treatments include some cognitive component, although some purists might not accept this.

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