Cognitive Behavioural Therapies (CBT) | Psychology

After reading this article you will learn about the Cognitive Behavioural Therapies (CBT) for the treatment of abnormal behaviour.

Cognitive behavioural therapies (CBT) emerged in the early 1960s by Ellis (1962). But the first major texts on cognitive behaviour modification appeared only in the, 1970s. The pioneers in this area are Hollon and Kendall (1978), Mahoney (1974), Meichenbaum (1977), Kendall (1978). Mahoney observed that like psychology clinical psychology had undergone a cognitive revolution during these years.

In view of this cognitive revolution in clinical Psychology, a number of models for cognitive and behavioural change have been advanced. CBT refers to a set of principles and processes which hold that cognitive processes affect behaviour and these processes can be changed through cognitive and behavioural techniques.

Cognitions include beliefs, belief systems and thoughts and images. Cognitive processes include ways of evaluating and organising information about the environment and self ways of processing information for coping or problems solving and ways of- predicting and evaluating future events.

CBT have three basic propositions:

1. Cognitive activity affects behaviour.

2. Cognitive activity may be monitored and altered.

3. Desired behaviour change may be affected through cognitive change.

According to Kazdin (1978) “the term cognitive behaviour modification encompasses treatments that attempts to change overt behaviour by altering thoughts, interpretations, assumptions and strategies of responding”. Hence cognitive behaviour therapy and cognitive behaviour modification are nearly identical so far as their basic assumptions are concerned.

The only difference between the two is perhaps with respect to treatment outcomes. While cognitive behaviour modification (CBM) intends overt behavioural change as an end result CBT focus their treatment effects on cognition per se, in the belief that behaviour change will follow. Cognitive behaviour therapy therefore is a much wider term than cognitive behaviour modification. Actually CBM is included within CBT.

The CBT refers to the proposition that the internal covert processes called thinking or cognition occur and these events may mediate behaviour change. These approaches also hold that behavioural change does not have to involve elaborate cognitive mechanisms.

Many cognitive behavioural theorists state that because of the meditational hypothesis not only is cognition able to modify behaviour, but it must modify behaviour so that behavioural change may thus be used as an indirect index of cognitive change.

The actual effect of CBT will differ from client to client. Emotional and physiological changes are also used as change indices, particularly when emotional or physiological disturbance is a major manifestation of the presenting problem of therapy (Dobson and Block).

It is further held by Dobson and Block that although CBT targets both cognitive and behaviour as primary change areas there are certain types of desired change that would clearly fall outside of the realm of cognitive behaviour therapy.

For instance, a therapist who focuses on head banging in an autistic child and adopts a classical conditioning approach to the treatment of this problem is not employing a cognitive behaviour therapy. Thus it is emphasised that any therapeutic regimen that adopts a stimulus response model is not a cognitive behaviour therapy.

Only where cognitive mediation can be demonstrated and where cognitive mediation is an important component of the treatment plan, it can be called cognitive behavioural therapy.

Results of researches conducted during the last several years show that CBT have clear advantages over other more traditional methods of treatment. Particularly the result is very important in the treatment of depressive patients.

A large number of research studies conducted by Blackburn, Bishop, Glen, Whalley and Christil (1981), Mcloan and Hakstain (1929), Rush, Beck, Kovacs and Hallon (1977), Simons, Garfield and Murphy (1984) show that cognitive behavioural therapies have had better therapy outcome than pharmacotherapy.

The National institute of Mental Health have conducted a very significant investigation on the relative effectiveness of cognitive behavioural therapy.

Some of the important therapeutic procedures coming under the CBT are:

1. Rational Emetive Therapy (RET)

2. Rational Behaviour Therapy (RBT)

3. Anxiety Management Training (AMT)

4. Problem Solving Therapy (PST)

5. Personal Science.

6. Structural Psychotherapy.

The CBT approach has been used for the treatment of depression. Depressed patients see themselves as “lossers”. Therapy is designed to make them feel like winners. Foreyt and Goodpick hold that the therapist will first select several target problems which can be emotional, motivational, cognitive, behavioural or physiological.

Each target problem is constituted at three levels i.e:

(1) In terms of abnormal behaviour such as inertia.

(2) In terms of motivational disturbances like trying to escape.

(3) In terms of cognitions of hopelessness and defeat.

In this technique the patient is told that keeping busy will make him feel better. Thus a daily activity schedule can be designed by the therapist and patient. The therapist can provide feedback about success relating to the daily activities of the patient to ensure that the patient is coming to think of himself as a “winner”. In this technique the cognitive change is actually more important than the behavioural change.

The patient must perceive and realise that he is doing some great meaningful work. This thought can bring a change in his behaviour. Negative self evaluation and feeling of failure being the main cause of depression under this category should be reversed at the cognitive level.

Beck (1976) is of view that self monitoring and self evaluation procedure is useful in helping depressed persons realise their potentiality for achieving success and to focus on the pleasurable aspects of their lives which they may fail to perceive as such.

In order to change maladaptive cognitive processes, the therapist can mould the patient to consider alternative explanations of experiences to show that there are other ways to interpret events besides those that reflect negatively on the self.

Beck’s cognitive therapy (1976) has shown some positive effect with severely depressed patients. Covert modelling which comes under CBT has shown some encouraging effects in the treatment of phobias and unassertiveness. Coping skills training has been used with test anxiety and to reduce indecisiveness.

Anxiety management training has not yet been sufficiently scrutinized to prove its effectiveness in various populations. Stress inoculation appears promising for dealing with anger, pain and performance anxieties.

Behavioural problem solving has been used successfully with pre-school students, emotionally disturbed children, adolescent, psychiatric in patients and delinquents. The Personal Science approach has been used with obese adults.

Currently the major tasks facing cognitive behaviour therapy are the following:

1. The development of more reliable methods for assessing cognitive phenomena.

2. The refinement and extension of knowledge regarding the casual impact of cognitive phenomena or other categories of experience.

3. The identification of parameters that influence the development, maintenance or change of particular cognitive patterns.

4. The incorporation of those parameters into pragmatic therapy procedures.

5. Continuing reappraisal of the assumptions and adequacy of the perspective.

In-spite of the criticisms against CBT by Eysenck (1979) and others if the above issues can successfully be dealt with, cognitive behavioural therapy can definitely be a major and successful technique during the coming years.

CBT tries to correct deficits and errors in the processes using a wide variety of persuasive and behavioural techniques. CBTs emphasize the importance of an operationally and methodologically sound approach for treating patients.

The ultimate purpose of CBT is to provide clients with the skills for regulating their own behaviours. Since CBT is based on social learning theory, it is amenable to experimental validation. Techniques used by the CBTs have their origin in basic research and can be empirically tested.

The work of Berman, Miller and Massman, 1985, Miller and Berman 1983 and Shapiro and Shapiro 1982 have helped the CBT in a tremendous way to make steady progress in research and practice. It is hoped that CBT will make considerable „ progress in the years to come.

Socio-cultural approaches to therapy:

(a) Institutionalization and after care.

(b) Community Health Services.

(c) Modifying Larger Social Systems.

Current clinical psychologists have charged the previous outlook with a sociocultural approach to the treatment of mental illness. The proponents of sociocultural approach favour the change in the individual’s life situation and circumstances to provide a congenial therapeutic environment.

This may include changing the home setting, changing the parental behaviour or changing the parental home altogether or staying in a boarding or residential or institutional environment. Juvenile delinquents and other types of behaviour disorders may be placed in the mental hospitals in the after care home or corrective centres.

Institutionalization and aftercare:

People with mental illness or behaviour disorders of different age groups starting from childhood to old age may be placed in mental hospitals or clinics. After they are cured and discharged, provisions for aftercare should be there.

Mental Hospital:

Nowadays along with the traditional treatment procedures, therapists consider it urgent to change the hospital environment into a therapeutic community. They believe that changing hospital environment is a vital part of the therapeutic programme.

Instead of keeping them very much restricted to the hospital ward, steps are taken to make atmosphere of mental hospital much more free and less restrained, less artificial for the patient. He must feel as if he is staying in the very familiar atmosphere of his own home.

Thus, the therapist tries to take the child nearer to the family and community setting. The patient is given as much freedom as necessary. The patients are also encouraged to take responsibility for their behaviour to manage their own affair, and to actively cooperate in the treatment programme.

This gives them some sort of self confidence. The hospital staffs are also trained to behave with the patients in human ways, with understanding, sympathy and tolerance.

In a therapeutic community i.e., in the hospital, interaction among the patients is planned in such a way so as to have therapeutic value. It has been observed that friendly and encouraging atmosphere, warm and stimulating setting elevates constructive and cooperative relationship.

The attitude to help each other, to share each other’s sorrow and anxiety, depression and worry also develop when the mental hospital becomes a therapeutic community.

Since the aim of hospitalization of mental patients is to enable the patients to make healthy adjustment with his fellow beings and ultimately to gain his previous position in the society, it is highly desirable for the psychiatrists to keep close contact with the family and community of the patient and deal with him accordingly.

Unless there is adequate aftercare, the percentage of relapse of the disease may increase. Therefore by suitable aftercare the percentage of readmission rate can be significantly reduced.

After being cured and discharged from the hospital, it still may be quite difficult for the patient to readjust with his environment. Consequently, about 45 to 50 per cent psychotic patients are readmitted within a year of their discharge.

By suitable aftercare service, the gap between hospital environment and community setting can be cemented and relapse cases can be reduced. By establishing day hospitals, halfway houses, aftercare service can be accelerated. Currently, the trend for opening day hospitals and halfway houses in Europe and more particularly in U.S.A. have increased.

According to Coleman (1981) currently, the day hospital is designed for two main functions:

(a) To provide an alternative to full time care and

(b) To act as a transitional centre between full time hospitalization and return to the community.

Halfway houses also help the former patients, alcoholics, drug addicts, to adjust normally in their society after institutionalization and also provide aftercare.

While in the hospital, besides other therapeutic measures discussed earlier the following therapeutic aids are also used.

(a) Biblio therapy:

The patients are provided specific reading materials keeping in view the needs of the patient such as with books, journals, pamphlets etc. This is done also with the purpose to let the patients know that there are also many people in this world who have similar problems like them. If necessary, they are also given the opportunity to take correspondence courses and to attend to educational institutions.

(b) Audio visual aids:

Like films, T.V. videotape play backs relating to therapy become extremely helpful to reduce behaviour disorder.

(c) Occupational therapy:

In this type of therapy the patients are kept engaged in constructive work, which will help the patient later on to lead his livelihood and to earn for his living. Besides, music therapy, art therapy, social events and gathering and athletics also supplement in the therapeutic procedures to correct maladaptive behaviour.

Community and mental health services:

Instead of treating all the mentally ill people in the closed environment of the hospital currently, attempts are made to treat them in the community or home setting why? Because, it is assumed that the environment is the most important source of psychological difficulties and it is in the environment all sorts of maladaptive behaviour have usually their genesis.

So by manipulating the environment plenty of psychological problems can be solved.

Community psychology has defined by Spector (1974) as follows:

“Community psychology is regarded as an approach to human behaviour problems that emphasises contributions made to their development by environmental forces as well as the potential contribution to be made towards their alleviation by the use of these forces.”

Thus, it is argued that since mental illness is contributed by the community, it can also be alleviated by changing the community. So environmental intervention is necessary to deal with disordered behaviour.

In community and mental health service centres immediate help is provided to the concerned persons instead of admitting them in the far off mental hospitals. The family life is not affected, neither the patient has to face the problem of adjustment in the distant and different hospital environments and its staff. Again adjustment problem arises when he returns back.

Langsley (1968) has reported a high percentage of cure of psychotics like schizophrenics and severe depressives through community and mental health services.

However, for the operation of community mental health services, certain problems need to be solved:

1. The family atmosphere must be conducive for therapy and the family and the community must cooperate with it instead of resisting to allow the mentally ill person to live with them.

2. Qualified and trained therapists must be available in the community.

The Community Mental Health Centres Act (1963) in U.S.A. provided federal assistance to communities for constructing such centres.

Up-to-date more than 400 centres have been constructed which provide mental health services to innumerable citizens of America in their home community in the following way:

(a) In patient care for persons requiring minor hospitalization.

(b) Partial hospitalization with day hospitalization for those who want to return home in the evening and night hospitalization for those who want to work in the day.

(c) Outpatient therapy.

(d) Emergency care when a patient needs immediate treatment.

(e) Consultation and education for members or the community.

Emphasizing the need of community health services Coleman has stated, “These community mental health centres are highly flexible and have a number of advantages. In fact, they can be of service to any people with different problems and needs. They can be of help to those who want to stay at home and be treated, those who need short term or long term hospitalization, those who want to be in job and be treated and things of the sort.”

He further adds “Such community centres usually utilise an interdisciplinary approach to therapy, involving psychiatrists, psychologists, social workers, nurses and other mental health personnel’s. Finally, such centres have many resources at their disposal, thus enabling the individual to obtain most or all of the needed services at one agency instead of travelling around the city from one place to another.”

Unfortunately in India, there is no record of provision for such community mental health centres.

Various free clinics and youth centres have also been opened in U.S.A. to provide counselling facilities for mental illness arising out of unemployment, crime and delinquency, family maladjustment; parent child relationship, marital problems like divorce and separation etc. Occasionally, services like job counselling, and remedial education are provided.

Changing social organizations:

Psychiatrists have currently felt the need for changing and modifying the maladaptive conditions of the social organisation, institutions, plants and work places. By giving sensitivity training, specially unfavourable aspects of social systems are being changed. Today psychological consulting firms are established in most of the organisations in the selection and training of personnel, to correct maladaptive group functioning arid to resolve organisational problems.

One of the important aims of community psychology is to prevent than to treat. So it supports the maxim that prevention is better than cure. How can mental illness be prevented? The answer is by manipulating the environment.

Caplan (1974), the guiding star of community psychology has suggested 3 different types of prevention programmes.

(a) Primary prevention i.e., change or manipulation of circumstances of the individual that might bring behaviour disorder, such as reducing crime, violence, crowding, indiscipline and dis-organisation in society. This can be possible by planning to produce healthy social conditions that can minimise personal crisis, anxiety, worry, frustration and stress.

(b) Secondary prevention. It tends to reduce the frequency of severity in an early detection and effective treatment of behaviour disorder.

(c) Tertiary prevention. Its purpose is to reduce the period of disability and reducing damage arising out of disordered behaviour. Tertiary prevention include psychotherapy, rehabilitation and hospitalization and other innovative methods to help mental patients to recover quickly and effectively.

According to Caplan behaviour disorder can be prevented by social action and interpersonal action i.e., improving the environment or providing ways to deal with both predictable and unpredictable crisis and face to face interaction with the therapist and an individual or group.

Evaluation:

Critics argue that lack of knowledge about prevention makes it more uncertain. The cost of prevention is very high. So poor people cannot afford it. In practice, rich people get more attention.

Finally, some argue that prevention interferes with personal privacy.