Understanding the Principles and Practices of Cognitive Behaviour Therapy
This essay intends to examine some of the principles and practices of Cognitive Behaviour Therapy an approach to therapy that has become a staple of modern day therapy and reflective professional practice based on ‘actively constructing a collection, selection and interpretation of data’ (Finlay and Gough, 2003, p.5). This examination will begin with a critical evaluation of the key principles and practices that underpin Cognitive Behaviour Therapy, beginning with its foundations and origins, its evolution, and some of the different ways in which it can be utilised. It will be shown that Cognitive Behaviour Therapy can be used to tackle a wide range of inhibiting problems, and there will also be a concise section of some of the common characteristics of Cognitive Behaviour Therapy, and how this helps to facilitate strategies to reduce and assist individuals cope with maladaptive behaviours.
There will also be a brief elaboration to how some of the theories of Cognitive Behaviour Therapy may also be applied to a social care setting, and throughout this essay differing social care perspectives will be considered.
Both the strengths and weaknesses of Cognitive Behaviour Therapy will be analysed, before balancing the positives and negatives and determining the usefulness of the approach. Finally, some tentative conclusions will be offered regarding the validity of using Cognitive Behaviour Therapy in a social care setting; and whether or not it is likely to remain one of the staple tools for helping people adjust and adapt to certain behaviours.
Cognitive behaviour therapy is a psychotherapeutic approach that assists in helping patients to understand why they behave the way that they do, more recently it has been used frequently to change negative or maladaptive behaviours through the therapeutic process, (O’Donohue & Fisher, 2008). To begin with it typically involves dealing with a very specific problem (such as an addiction, phobia, or anxiety), thus the core idea behind Cognitive Behaviour Therapy is that thoughts and feelings have a direct impact upon people’s behaviour.
Cognitive Behaviour Therapy is grounded by the work of Ivan Pavlov (1927), who examined techniques of animal learning (and his famous classical conditioning experiments); and since then, Cognitive Behaviour Therapy has gone on to build a solid foundation of empirical evidence of its success. It is an approach that was developed by the founding fathers, Aaron T. Beck and Albert Ellis (Hofmann, 2012).
Simmons and Griffiths (2009, p.8) state that Cognitive Behaviour Therapy has “developed through rigorous research and outcome studies” which really began in earnest in the 1970s, from then many behavioural researchers and therapists began to lean towards a more cognitive approach and ‘self-instructional training’. Simmons and Griffiths (2009, p.8) also go on to state that “As Cognitive Behaviour Therapy has become more widespread, it has been subjected to rigorous outcome research and has been shown to be a valuable approach with a considerable range of psychological problems”. It may be considered perhaps that this flexibility associated with Cognitive Behaviour Therapy has in fact contributed to its growing popularity.
Greenberger and Padesky (1995) provide a succinct and simplistic explanation which involves the examination of an individual’s thought and belief system which connect and contribute to people’s moods and physical experiences. In short, it is the idea that people’s thoughts have a direct impact on their emotional responses. Cognitive Behaviour Therapy is therefore a combination of cognitive psychology, which is the analysis of mental processes, and behavioural therapy, which focuses on behaviours and how that behaviour was learned (so therefore, it can then be ‘unlearned’ through processes such as aversion therapy). In essence providing the best of both worlds, and the two approaches complement each other and enhance a more holistic approach.
To outline what Cognitive Behaviour Therapy is and where it came from, Bakker (2008, p.5) states that
“Cognitive Behaviour Therapy, having grown out of the behaviour therapies, rests on a mass of well-established learning theory and conditioning theory research, dating back to Watson and Pavlov and burgeoning especially in the 1950s, 1960s, and 1970s. It therefore uses many of the same processes and techniques, such as rehearsal, coaching, reinforcement, modelling, extinction, and so on”
Moreover, Bakker (2008) also discusses how clients can learn to overcome their problems by finding new ways to function by adaptation. He states “As a process this is usually therefore active, progressive, time-limited, and goal-oriented” (Bakker, 2008, p. 5), as Cognitive Behaviour Therapy is commonly concerned with what is maintaining causes of distress (rather than what actually triggered it). For example, it might not be clear as to what has caused a certain phobia to arise (the trigger), but what is helping to maintain that phobia can often be addressed, thus strategies can be formed to help to cope with it. Moreover, Robertson (2010. p.3) further explains this idea by saying that “Cognitive Behaviour Therapy is concerned with helping clients to deal with irrational or disturbing emotions, and to cultivate rational, healthy and proportionate ones in their stead”.
According to O’Donohue and Fisher (2008), there are numerous reasons why Cognitive Behaviour Therapy has become so popular in recent years; some of these reasons include mounting empirical evidence which justify how it is effective. It would be reasonable to suggest that it is cost effective due to therapy tending to be relatively brief and the fact that it can be done in groups, it can be utilised for a wide range of problems, it is a relatively straightforward and uncomplicated approach to therapy, and there being many individual techniques that can be drawn from within the Cognitive Behaviour Therapy system for therapeutic purposes. This may substantiate claims that exist that there has been a dramatically increased evidence base which appears to have occurred over the last two decades as Dobson and Dobson (2009, p.1) state that “Cognitive-behavioural therapy has broad evidence as a powerful intervention for mental health problems in adults”. References such as this should be reflected as key endorsements when considering implementations for improving future practice, and ones that should not be ignored
Indeed, Cognitive Behaviour Therapy has many advocates, and Hofmann (2012) even goes as far as to say that it is at least as effective as medication for certain problems, and that it is a highly effective strategy for dealing with many psychological problems. These too are grand claims, but ones that must have some backing due to the increasing popularity as a form of therapy.
In the context of social care, Cognitive Behaviour Therapy has the potential to be applied to a wide range of problems, such as addictions (drugs, alcohol, sex, food, etc.), abuse (physical or mental), youth delinquency, crime, food disorders (such as anorexia or bulimia), phobias (such as agoraphobia), and many other social problems, (Woolfe et al, 2003). Due to this flexibility, along with much empirical evidence to support its effectiveness, this has led it to being one of the most used of therapeutic approaches in social care settings.
There are a number of different phases in the process of Cognitive Behaviour Therapy, and this begins with an initial assessment that is done via a structured or semi-structured interview, followed by a ‘reconceptualisation’ phase (creating a new concept for something such as focusing on the ill effects of drugs rather than the pleasure), skills acquisition (such as finding new ways to cope with negative feelings), and numerous follow up phases such as reinforcement and follow up assessments by the therapist (Beck, 1995).
There are many specific techniques which can be utilised. A selection of some of these techniques include, behaviour therapy, anger control therapy, biofeedback, and sex therapy (Bakker, 2008, p. 8). Therefore this would substantiate the claim that Cognitive Behaviour Therapy appears to have a considerable collection of empirically supported theory-based practices.
However, the crux which underpins therapeutic techniques is that cognitive activity affects behaviour, cognitive activity can be monitored and changed, and that desired behaviour change may be achieved through cognitive change (Robertson, 2010, p. 4).
For example, a child who has a prolific history of petty and minor offending is caught shoplifting, and social services who have worked with the child and the family intensively in the past reinvestigate and find that the child is now being brought up by the mother (singularly), she has a long medical history of depression. This condition may be inhibited her from providing basic parenting, and reducing the attention and care she gives to the child.
To improve this situation it is possible that a social worker may recommend that the mother attends a series of Cognitive Behaviour Therapy sessions, and (worst case scenario) the child is to be accommodated in temporary care until the issue is resolved or significantly alleviated. The role of the therapist would be to monitor the mother’s negative automatic thoughts and cognitions, to evaluate the relationship between her thoughts, feelings and actions, to evaluate the evidence for these maladaptive cognitions, to create alternative cognitions to substitute the negative ones, and to identify and modify the underlying assumptions and beliefs that predispose her towards negative automatic thoughts (Robertson, 2010, p. 4).
By giving the mother a strategy for coping with her depression (instead of medication), she may be able to better adapt to her circumstances, and her child may also be more likely get more attention and stop the attention-seeking behaviour that brought the mother to the social worker’s attention in the first place.
However, it is wrong to describe Cognitive Behaviour Therapy as simply just ‘thinking positively’; a frequently used definition implies that it is “infinitely more complex than this”, (Simmons & Griffiths, 2009, p. 5).
Some more characteristics include being a therapeutic style (with the therapist being more active and involved rather than being a passive listener), a psychological formulation of a problem (a ‘big picture’ of why the client is experiencing their problem), a collaborative relationship (with the client and the therapist very much working together), a structured therapy session (creating a problem-solving atmosphere), a goal directed therapy session (determined by client and therapist), an examination and questioning of unhelpful thinking (through a series of questions), a use of a range of aid and techniques (determined by the psychological formulation), teaching the client to be their own therapist (which helps to empower them and allows them to be independent when the therapy schedule is complete), using homework and assignments as part of the therapy (allowing clients to work between sessions), a time-limited exercise (pushing clients to become their own therapist), and sometimes the audio-recording of sessions for later analysis (Simmons & Griffiths, 2009, p. 5).
In addition, with regard to using Cognitive Behaviour Therapy, specifically in a social care setting, Ronen and Freeman (2007) argue that social workers have become the backbone of mental health practice, and that clinicians recognise the need for a model of treatment that is active, short-term, directive, problem-oriented, solution-focused, collaborative, structured, dynamic, and psychoeducational interventions.
They state that “The goals of clinical social work must include helping individuals, families and groups to be happier, more personally fulfilled and more productive. It is essential, however, that the strategies (goals) and interventions (techniques) used to reach these collaboratively set goals are measurable, reasonable, proximal, and realistic. It is far more important in the short term to get better than to feel better. It is, in fact, the quest for short-term gain that often will lead individuals into the avoidance seen in the anxiety spectrum disorders, substance misuse, or eating disorders” (p.xxiv)
Social care work is consequently about supporting, protecting and empowering vulnerable individuals, groups and communities. Therefore Cognitive Behaviour Therapy in this environment would mainly be about empowerment (although it could also be about protection from such things as drug overdoses or suicide attempts). It allows clients to build short-term coping strategies to mitigate maladaptive behaviours, and to teach them how to continue with this on their own once the therapy schedule has run its course.
Parrish (2010 p.1) states that “The ability to observe and understand people’s behaviour is an essential component of effective social work practice”. Tools such as Cognitive Behaviour Therapy may combine and become essential for social care workers to reach their goals. For example, cognitive restructuring (a therapeutic tool used in Cognitive Behaviour Therapy) could be used to essentially reprogram negative thoughts and assumptions that lead to maladaptive behaviour, and replace them with more positive schematic patterns (Hepworth, Rooney, Rooney, Strom-Gottfried & Larsen, 2010, p. 390).
Therefore it could be considered that Cognitive Behaviour Therapy techniques are based upon the idea that people construct their own reality, and that their behaviour is a result of cognitive processes and their own unique inner dialogue. By changing this inner dialogue, people can thus change their behaviour, and this is what Cognitive Behaviour Therapy attempts to do.
However, it has been noted by Walsh (2010) that this approach is better suited to people with obsessive personality styles rather than avoidant personality types. Moreover, there is also some empirical evidence to suggest that Cognitive Behaviour Therapy is in fact more effective with clients that are married rather than single or non-cohabiting clients (Walsh, 2010, p. 182). Thus, whether this approach is implement or not in a social care setting will very much depend on the clients’ personality type and situation, with other therapeutic approaches (such as interpersonal psychotherapy) being more suited to certain types of client. Although Cognitive Behaviour Therapy is flexible and adaptable, it is certainly not an approach that will suit everyone.
Finally, Thomlison and Thomlison (2011) claim that it was not until the late 1960s that this approach first began to appear in social care practices (with it coming to prominence as mentioned in the 1970s), they also point out a number of criticisms. For example, behavioural therapy traditionally consists of observing behaviour and then modifying it through new learned responses. However, it could be said that thoughts and feelings are not observable in the same way via a third party—and therefore cannot be objectively validated in the same way that behaviour can. Moreover, it has also been noted that Cognitive Behaviour Therapy is not very helpful for people who are not comfortable with reflection. However, on the whole it does seem that this approach has more advocates than critics, and that these criticisms are generally brief and unsubstantial.
In conclusion, it would appear that Cognitive Behaviour Therapy can and is becoming an important tool of contemporary within social care practices. The fact that Cognitive Behaviour Therapy techniques are so flexible, and that they can be applied to so many different social problems, makes it almost the perfect strategy and tool for social care workers dealing with clients that have maladaptive behaviours. However, it has been noted that this approach is not a one-fit for all strategy, and that it is only suited to certain personality types who are receptive to introspection and the analysis of their thoughts and feelings.
With a wealth of empirical evidence pointing to the effectiveness of using Cognitive Behaviour Therapy it is likely that social care workers will continue to recommend its use for clients that have certain problematic behaviours and issues.
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