A Brief History of CBT

[reproduced from sage pub.com : http://www.sagepub.com/upm-data/66994_39347_978_1_84860_687_6.pdf]

Modern CBT has two main influences: first, behaviour therapy as developed by Wolpe and others in the 1950s and 1960s (Wolpe, 1958); and second, the cognitive therapy approach developed by A.T. Beck, beginning in the 1960s but becoming far more influential with the ‘cognitive revolution’ of the 1970s.

In this spirit, BT avoided speculations about unconscious processes, hidden motivations and unobservable structures of the mind, and instead used the principles of learning theory to modify unwanted behaviour and emotional reactions. For instance, instead of trying to probe the unconscious roots of an animal phobia, as Freud famously did with ‘Little Hans’ (a boy who had a fear of horses: Freud, 1909), behaviour therapists constructed procedures, based on learning theory, which they believed would help people learn new ways of responding. The BT view was that someone like Little Hans had learned an association between the stimulus of a horse and a fear response, and the task of therapy was therefore to establish a new, non- fearful, response to that stimulus. The resulting treatment for anxiety disorders, known as systematic desensitisation, asked clients to repeatedly imagine the feared stimulus whilst practising relaxation, so that the fearful response would be replaced by a relaxed response. Later developments often replaced imaginal exposure (e.g. thinking about a mental picture of the horse) with in vivo exposure (approaching a real horse).

BT rapidly became successful, especially with anxiety disorders such as phobias and obsessive-compulsive disorder (OCD), for two main reasons. First, in keeping with its roots in scientific psychology, BT had always taken an empirical approach, which soon allowed it to provide solid evidence that it was effective in relieving anxiety problems. Second, BT was a far more economical treatment than traditional psychotherapy, typi- cally taking six to 12 sessions.

The ‘First Wave’ Revolution in Cognitive-Behavioural Science

Behaviour therapy (BT) arose as a reaction against the Freudian psychoanalytic paradigm that had dominated psychotherapy from the nineteenth century onwards. In the 1950s, Freudian psychoanalysis was questioned by scientific psychology because of the lack of empirical evidence to support either its theory or its effectiveness (Eysenck, 1952). BT was strongly influenced by the behaviourist movement in academic psychology, which took the view that what went on inside a person’s mind was not directly observable and therefore not amenable to scientific study. Instead behaviourists looked for reproducible associations between observable events, particularly between stimuli (features or events in the environment) and responses (observable and measurable reactions from the people or animals being studied). Learning theory, a major model in psychology at that time, looked for general principles to explain how organisms learn new associations between stimuli and responses.

The ‘Second Wave’ revolution in Cognitive-Behavioural Science

Despite this early success, there was some dissatisfaction with the limitations of a purely behavioural approach. Mental processes such as thoughts, beliefs, interpretations, imagery and so on, are such an obvious part of life that it began to seem absurd for psychology not to deal with them. During the 1970s this dissatisfaction developed into what became known as the ‘cognitive revolution’, wherein ways were sought to bring cognitive phenomena into psychology and therapy, whilst still trying to maintain an empirical approach that would avoid ungrounded speculation. Beck and others had in fact begun to develop ideas about cognitive therapy (CT) during the 1950s and early 1960s, but their ideas became increasingly influential. The publication of Beck’s book on cognitive therapy for depression (Beck et al., 1979), and research trials showing that CT was as effective a treatment for depression as anti-depressant medication (e.g. Rush, Beck, Kovacs & Hollon, 1977), fuelled the revolution. Over the succeeding years, BT and CT grew together and influenced each other to such an extent that the resulting amalgam is now most commonly known as cognitive behaviour therapy – CBT.

The ‘Third Wave’ revolution in Cognitive-Behavioural Science

‘Third wave psychotherapies’ comprise a heterogeneous group of treatments, including acceptance and commitment treatment, behavioural activation, cognitive behavioural analysis system of psychotherapy, dialectical behavioural therapy, metacognitive therapy, mindfulness-based cognitive therapy and schema therapy. Several randomized controlled trials, longitudinal case series and pilot studies have been performed during the past 3–5 years, showing the efficacy and effectiveness of ‘third wave psychotherapies’. The third wave of behavioural psychotherapies is an important arena of modern psychotherapy. It has added considerably to the spectrum of empirically supported treatments for mental disorders and influenced research on psychotherapy. [http://www.medscape.com/viewarticle/772441]

Some of the main theoretical difference seems to be about control and emotional avoidance. Third wave therapists have sparked a re-examination of whether trying to control our thoughts and emotions is part of the solution – or the problem. They believe that there may be other non-traditional ways to address the way we deal with our thinking. This theoretical question has stimulated renewed efforts for cognitive-behavioral therapists to improve their ability to not just work with the content of our thoughts but the process of thinking itself. In other words trying not to just change what we think but how we think.

Philosophically, third wave therapies have a decreased emphasis on controlling our internal experience; they offer a more eastern approach to our psychological lives. Many of these therapies are incorporating the role of acceptance and mindfulness into traditional CBT. However we relate to our thoughts, the third wave therapist wants thoughts to help our behavior to be adaptive. Are our reactions to our thoughts flexible enough to be consistent with leading valuable, productive lives, or are our efforts at controlling our thoughts and emotions taking up all of our attention and energy? [from Suffolk Cognitive Therapy]

CBT IN THE TRAUMA FIELD

My Personal Approach

My training as a psychotherapist included some behavioural and cognitive science, its rationale and strategies. But it was not labeled specifically as ‘CBT’, being presented rather as a natural part of our understanding of human psychology. By 2015, CBT strategies are simply an integral part of most therapists’ toolkits, and my guess would be that psychotherapists are more likely to embrace the ‘third wave’ philosophy of cognitive and behavioural science, whereas a glance at some ‘psych’ websites indicates that ‘second wave’ CBT is still regarded as the important part of a psychologist’s mode of treatment. In the end, all the evidence-based research and practice over the last 60 years is valuable and useful. CBT sits in this website as a valuable part of the journey of healing, but my particular way of using it is a ‘softer’ version.

When I work with a client and introduce ‘CBT’ techniques, I don’t think of it as CBT. I conceptualize it rather as working with that person’s brain to help them learn HOW to work with their own system – and that system is a full mind-body-spirit system. By now, with the knowledge we currently have about the brain, CBT techniques are commonsense. But I don’t give homework sheets or structured handouts. I just demonstrate: this is how your brain works, this is how it interacts with your body and emotions, now what do we need to do to make it all work for you?

If a client is ready for this kind of focused work, they will want to practice it between sessions, especially when they see how well it works. But for many people healing from Complex PTSD, in the earlier stages, CBT techniques will not work well. The reason for this is that the ‘inner child’ part of them, ie the implicit memories, needs to be listened to, validated, comforted, felt about and expressed. It is vitally important to do these tasks before the more controlling CBT interventions are implemented. If you don’t, the ‘inner child’ part will perceive the intervention as just one more example of how authoritative adults always try to control them – and they will tend to resist, put up barriers within the self, knuckle down and unconsciously say to themselves – ‘I won’t let myself be controlled, I won’t comply and I won’t co-operate.’

Exposure Therapy

Exposure therapy, is one form of CBT unique to trauma treatment which uses careful, repeated, detailed imagining of the trauma (exposure) in a safe, controlled context, to help the survivor face and gain control of the fear and distress that was overwhelming in the trauma. In some cases, trauma memories or reminders can be confronted all at once (“flooding”). For other individuals or traumas it is preferable to work gradually up to the most severe trauma by using relaxation techniques and either starting with less upsetting life stresses or by taking the trauma one piece at a time (“desensitization”).

Other CBT strategies to complement Trauma Therapy

Along with exposure, CBT for trauma includes learning skills for coping with anxiety (such as breathing retraining or biofeedback) and negative thoughts (“cognitive restructuring”), managing anger, preparing for stress reactions (“stress inoculation”), handling future trauma symptoms, as well as addressing urges to use alcohol or drugs when they occur (“relapse prevention”), and communicating and relating effectively with people (“social skills” or marital therapy).

THE AIM OF COGNITIVE BEHAVIOURAL THERAPIES :

TO MODIFY COGNITIONS BY

PRACTISING THE ABC-D-E MODEL

IDENTIFYING IRRATIONAL / FAULTY BELIEFS

RECOGNIZING THE ‘TYRANNY OF THE SHOULDS’

LEARNING NOT TO CATASTROPHISE

MONITORING YOUR THINKING

TO CHANGE BEHAVIOURS BY

CONFRONTING FEARED SITUATIONS

ASSERTIVE COMMUNICATION

PRACTISING DEEP RELAXATION

PRACTISING PROBLEM SOLVING

SETTING GOALS [link to article]

ACCEPTING AND UTILIZING SOCIAL SUPPORT SYSTEMS

SCHEDULING ACTIVITIES