Cognitive Behavioural Therapy

Cognitive psychologists believe that psychological disorders, for example depression, and anxiety stem from faulty or irrational thinking, and if a person is to be cured of these disorders then thinking patterns need to be changed. The aim of CBT is to replace these irrational thought processes with rational ones, thus helping patients’ process information on a more logic level.   

The assumption that internal processes, such as perception, impact on our behaviour underlies the principles of CBT as the role of the therapist is to help the client change their perception of the world around them, as they are causing the illness. This can be achieved through cognitive reconstructing, where the therapist questions the evidence base for the client’s perception. Often, the client will see for themselves that their perceptions are not based on any real evidence, and this can elicit change. Schemas are mental structures that represent an aspect of the world. All of our mental processes work together within a split second to allow us to respond to the world around us. Most individuals’ mental processes are based on rational reasoning. Mental problems occur when individuals have negative schemas. Aaron Beck proposed that depressed people have developed negative schemas of three things- themselves, the world around them and the future. 

CBT combines both cognitive and behavioural techniques in order to help clients: 

The cognitive element- identify and alter these negative cognitions 

The behavioural element- the therapist encourages the client to engage in reality testing, either during the session or as a homework. 

Some of the techniques used in CBT are as follows: 

Dysfunctional thought diary: As homework, clients are asked to keep a diary of thoughts and feelings associated with any negative events. They have to pay particular attention to any automatic negative thoughts. For each negative thought they have to rate how much they believe this (from 0%-100%). They then give a rational response to this thought, and rate their belief in that. Finally, they rerate their belief in the automatic thought.

Cognitive Restructuring– Individuals are taught how to see the link between their thoughts and the way they feel.  They might, as part of their ‘homework’, be asked to record any emotion-arousing events, the ‘automatic ‘negative’ thoughts associated with these events, and then their ‘realistic’ thoughts that might challenge these negative thoughts. During CBT, they are taught to challenge this association, through questioning. By challenging these dysfunctional thoughts, and replacing them with more constructive ones, clients are encouraged to try out new ways of thinking and, ultimately behaving.

Behavioural Activation- that being active leads to rewards that act as an antidote to depression.  A characteristic of many depressed people is that they no longer participate in activities that they previously enjoyed.  In CBT, therapist and client identify potentially pleasurable activities and anticipate and deal with any cognitive obstacles . The technique involves asking clients to keep a record of their experience, noting how they felt and what the specific circumstances were. If it didn’t go as planned, the client is encouraged to explore why and what might be done to change it.  By taking action that moves towards a positive solution and goal, the patient moves further away from negative thinking and maladaptive behaviour

There is an impressive body of research supporting the effectiveness of CBT in the treatment of depression.  Butler et al (2006) concluded that CBT was a highly effective for treating depression. Nevertheless, NICE recommends CBT as the most effective psychological treatment for moderate and severe depression.However, Holmes (2002) claims that the single largest study into effective treatments for depression (NIMH) showed that CBT was less effective than antidepressant drugs and other psychological therapies. In addition, Holmes argues that the evidence for the effectiveness of CBT comes mainly from trials of highly selected patients with only depression and no additional symptoms. 

A number of studies have compared the effectiveness of CBT with drug therapy in terms of treating severe depression. Jarrett et al (1999) found that CBT was as effective as some anti-depressant drugs when treating 108 patients with severe depression over a 10 week trial. However, Hollon et al (1992) found no difference in CBT when comparing a slightly different kind of anti-depressant drug in a sample of 107 patients over a 10 week trial. This suggests that CBT is not superior to all antidepressants.  March et al (2007) explored the possibility that combining antidepressants with CBT might reduce this risk. He found about 15% of those on the drug treatment expressed such thoughts, compared to 6% of those with CBT.

It is difficult to establish whether depression causes negative thought process or vice versa. Also the assumption that peoples thought process are irrational could be flawed. These thoughts processes may be rational and healthy in stressful situations.CBT appeals to clients who find insight therapies too threateninga and  empowers clients to develop their own coping strategies and recognise that people have free will to do this.CBT has become an increasingly popular alternative to drug therapy and psychoanalysis, particularly for people who could not cope with the determinist principles of these approaches. Although CBT is criticised for ignoring the influence of unconscious dynamics and for minimising the importance of past events and some clients do become dependent upon their therapist.CBT appears to be less suitable for people who have high levels of dysfunctional beliefs that are both rigid and resistant to change. Patient Blame the cognitive approach to therapy assumes that the client is responsible for their disorder and important situational factors may be overlooked which are contributing to their disorder, such as family problems of life events that the client is not in a position to change. Therefore ‘blaming’ the individual for the way they think/feel is not necessarily helpful because it may take other aspects of their life to change in order to help them feel better. Another ethical debate concerns who judges an ‘irrational’ thought. Come thoughts that a therapist deems irrational may in fact not be. The ethical issue is that CBT may damage self-esteem, an example of psychological harm.