Awareness of Cognitive-Behavioral Therapy - Coursework Example

Awareness of Cognitive Behaviour Therapy Introduction Several diverging approaches have developed in psychology to help better understand human behaviour. The core focus of this analysis is to undertake a critical evaluation of the cognitive behavioural approach to therapy. In undertaking the evaluation, this paper will examine various facets of the cognitive behavioural model with a practical application to the factual scenarios provided in Case Study 1 and 2. Firstly, from a historical perspective as part of background understanding to the current cognitive behavioural therapy model, Woolfe and Dryden cite philosopher Epictetus' observations that people are disturbed by the view that they take of events rather than the actual occurrence of these events as the theoretical origins of contemporary cognitive behavioural therapy (CBT) (Woolfe and Dryden, 1996). It is further submitted that CBT arguably radicalised established psychotherapy theorem in focusing on the interrelationship between cognitive and behavioural psychological models of human behaviour (Grazebrook and Garland 2005). The earlier of the two approaches centred on behaviourism as extrapolated by JB Watson, who believed that psychology should concern itself with overtly observable factors as opposed to Freudian psychodynamic theorem (McLeod, 2003). Indeed, the majority of psychodynamic theories stem from Freud and are rooted in the overall objective of understanding how influential the mind is in shaping our personalities and behaviours (McLeod, 2003). His fundamental core belief was that the mind was the most powerful influence on an individual's actions. To this end, it is arguable that the focus on the mind can be reconciled with cognitive behavioural therapy however Freudian theory is rooted in strict categories, which undermines the notion of the individual and self postulated by CBT. For example, Freudian psychodynamic theory propounds that the mind has three essential components as set out below: 1) The conscious: that part of the mind responsible for dealing with our everyday actions at any given moment of the present; 2) The pre-conscious: the part of the mind responsible for storing easily accessible memories of past events; and 3) The unconscious: that part of the mind responsible for storing easily accessible memories of past events, particularly traumatic events (Gross, 2005). This is often referred to as the "ego". Freud further describes the development in psychosexual stages being; the oral age (between 0-1.5yrs), anal age (between 1.5-2yrs), phallic age (between 3-5yrs), latency (between 5-12yrs) and genital age (between 12 -20yrs) (Nelson-Jones, 2006). Each stage is marked with individual challenges and conflicts and from these psychosexual stages Freud attaches most significance to the phallic stage with regard to the long term impact on individual development in later life, which is pertinent to the factor of Clare's sexual abuse in childhood. Conversely, one of the primary theories pioneered by behaviourists such as Skinner, Watson, Pavlov, Tolman and Thorndike was that all behaviour and beliefs must be learned and they undertook controlled laboratory experiments to ascertain how such beliefs were learned (McCleod, 2003). This was further developed by Pavlov's classical conditioning model and Skinner's operant learning model, which developed early behaviourism theory into a systematic therapy model, further providing the foundation for the Systematic Desensitisation Technique (McLeod, 2003), put forward by Wolpe (Gross, 2005). Moreover, Tolman ran a series of laboratory physiological experiments to test the theory, which led him to believe that they had created a mental map of the mind, which fuelled the study of internal mental events "cognitions" into behaviourism theory (Gross, 2005). This "cognitive revolution" arguably reversed the previous limitations of stimulus response analysis of human behaviour with inner, mental events or cognitions returned to govern psychology (Gross, 2005). Moreover, it went further in tallying sophisticated research methods to develop a theory/treatment model as opposed to introspective hypothesising (McLeod, 2003). CASE STUDIES, THEORY AND DEPRESSION The roots of cognitive behaviourism are clearly significant in developing psychology theorem into a basis for a practical treatment model, contrasting with the introspection of Freudian psychodynamic theory, which is arguably dogmatic in ignoring the subjective requirements of the individual, by focusing on categorisation of patients into somewhat artificial slots. The dichotomy between psychodynamic theory and cognitive behavioural is further highlighted if we consider the differences in approaching clinical depression (Kaplan & Saddock, 2007). Depression is triggered by the interrelationship of multiple causes and the psychodynamic explanation focuses on processes of change and development and the dynamics of behaviour, or the forces that drive an individual to behave in a way that they do. Freud further believed that it is the unconscious that exerts the most influence upon behaviour (Gross, 2005). He maintained that all explanations of behaviour and actions stemmed from the inaccessible areas which made up four fifths of the mind (Nelson-Jones, 2006). Moreover, Freud likens depression to grief, it can occur as a reaction to loss in a relationship. He argues that depression does not evolve in reaction to loss of a loved one, but caused by re-experience of a loss as a child, which interlinks with the attachment theory (Vronsky, 2004). Indeed, many leading psychodynamic theorists claim that it is the loss of self-esteem that leads a person down the path of depression (Vronsky, 2004). Moreover, the attachment theory argues that infancy is central to the proper development of the adult personality (Vronsky 2004). Indeed, it has been propounded that the first twelve months are critical to the development of emotions such as remorse and affection (A, Alexandrovich & D, Wilson. 1999). Moreover, failure to attach or bond through adequate attention and physical touch during this time period, has demonstrated increased risk of personality disorder development in later life, which is evident in Clare's history of childhood abuse (Canter. 2005). If we further consider this by analogy to the Jeremy's situation as highlighted in Case Study 1, within the cognitive model, his behaviour and feelings are in line with the CBT paradigm of "maladaptive behaviour and negative emotions" (Ellis, 1973). Jeremy's behaviour further demonstrates "a pattern of unwanted behaviour accompanied by distress and impairment" (Chakrabort & Mckenzie, 2001). Chakrabort & Mckenzie, argue that CBT is a recommended treatment option for "a number of mental disorders, including affective (mood) disorders, personality disorders, social phobia, obsessive-compulsive disorder, anxiety, or panic disorder, post traumatic stress disorder" (Chakrabort & Mckenzie, 2001). Jeremy's behaviour appears to display overt signs of depression and anxiety and Chakrabort & Mckenzie, further argue that racism is a common phobia that can lead to a debilitating mental and physical affectation of the recipient, such as depression, inferiority complexes (Kaplan & Saddock, 2007). To this end, Chakrabort & Mckenzie, submit that CBT is an appropriate method of encouraging positive and progressive thought, self-esteem and education and positive communication efforts (Chakrabort & Mckenzie, 2001). Moreover, the NICE guidelines for treatment and care of people with depression and anxiety assert that "Depression is characterised by a low mood and loss of interest, usually accompanied by one or more of the following - low energy, change in appetite'. feelings of guilt or worthlessness and suicidal ideas". The fact that Jeremy has become withdrawn, lacks interest and schoolwork is suffering is in line with the NICE classification of depression. Moreover, the fact that he is displaying suicidal tendencies further correlates to the NICE classification of depression. With regard to depression, the NICE classification specifically recommends CBT as a treatment for mild depression and as being as effective as drug alternatives. With regard to Claire, her symptoms clearly fit into Chakrabort & Mckenzie's assertions regarding anxiety. Moreover, the NICE guidelines stipulated that "anxiety is characterised by feelings of apprehension and worry, spontaneous panic attacks, irritability, poor sleeping, avoidance and poor concentration". One of the three intervention methods specified by the guidelines as a course of recommended action is CBT. However, within the field of CBT, contention exists with regard to the appropriate CBT model for treatment. VARIOUS CBT MODELS The presumptions established in early CBT theory were re-defined significantly by pioneering psychoanalysts Ellis and Beck. On the one hand, Ellis' therapy model was arguably more interactive than associated cognitive therapy and labelled Rational Emotive behaviour therapy (REBT) (Ellis, 1973). This therapy model was rooted in increased levels of challenge and confrontation during therapy, which enabled the client to scrutinise their "irrational beliefs" or "crooked thinking", which Ellis believed stemmed from seeing life in terms of "musts" or "should" which he claimed were invariably exaggerated or overstated and the cause of emotional problems (McLeod, 2003). Ellis' ABC model of human disturbance ignores any concept of infant loss or attachment theory model contributing to predisposed depressive states. The ABC symbolises the following: 1) A - is the actualising event, 2) B represents the individual perception and beliefs about the trigger event; 2) C stands for the emotional or behavioural consequence between A and B (Ellis, 1973). Under the REBT treatment model, events and resultant emotional consequences are determined by belief about the event rather than the actual event (McLeod, 2003). As such, the REBT model appears to reject any interrelationship between infancy, loss and trigger events with behavioural tendencies. However, Ellis arguably goes too far and the inherent flaw in this theory is that it ignores cogent evidence pointing to the significant role that physiological factors play in influencing the mind and behavioural patterns as evidenced by credible psychodynamic theory. Moreover, it is submitted that particularly with regard to the history of Clare's sexual abuse, such an approach would be inappropriate and potentially detrimental to her therapy. For example, leading academic Vronsky's research into the attachment theory and development of the self clearly undermines Ellis' REBT treatment model, particularly in context of research into the psychology of serial killers. For example, Vronsky argues that there may be signs that the child has a psychopathic personality by the age of 2 (Vronsky 2004). It is further argued that an infant develops a sense of only itself and it is the very nature of isolation, which breeds the fantasy world (D, Wilson., 2001). Therefore with regard to any CBT intervention in Clare's situation, whilst the REBT model may assist in identifying the "actualising event" and its interrelationship with Clare's behaviour, the therapy approach must adopt an empathetic understanding of the sense of loss. Similarly, it is submitted that such an approach is far better suited to Jeremy's treatment, particularly in light of the recent display of suicidal tendencies. Additionally, Wilson argues that the failure to bond in conjunction with other socio-economic factors leads to increased isolation of the individual. Another common characteristic is the relationship of the patient with their mother. Moreover, Freud argues that males try to reach a stated of autonomy with their mother, and failure to do so results in the development of inner rage (B, Masters. 1985). As such, in light of the complex factual scenarios raised in the case studies it is submitted that psychotherapy treatment models should consider research into the interrelationship between psychodynamic theory and CBT going forward rather than continue to diverge into polarised entrenched positions. BECK'S CBT APPROACH At the other end of the cognitive behavioural spectrum, Beck's psychoanalytic background resulted in a common denominator regarding the impact of the patient's cognition on emotions and behavioural traits, which it is submitted at the outset is more likely to be an appropriate starting point to any cognitive intervention in Jeremy and Clare's case. Beck's theory propounds that incorrect habits of interpretation and processing are developed during cognitive development (Beck, 1976). This basic theory underlines contemporary CBT models. The first concept is that schemas, cognitive structures of people's fundamental beliefs and assumptions can be adaptive or maladaptive (Nelson-Jones, 2006). Secondly, Beck propounds the various "Modes of cognition", interpret and adapt according to persisting situations (Beck and Weishaar, 2005). Another is cognitive vulnerability, which is the human's cognitive inherent frailty unique in varying degrees to each individual and founded on their subjective schemas (Nelson-Jones, 2006). Clearly this is evident in the variances in "fragility" of both Clare and Jeremy respectively. To this end, Beck's CBT vision adopts a pragmatic approach and is rooted in three central assumptions. Firstly that behaviour can largely be explained in terms of how the mind operates, the mind is similar to a computer inputting, storing and receiving data and that psychology is a science based mainly on laboratory experiments. Indeed, Beck and Clark (1988) argued that cognitive factors may play an important role in the development of depression. They have referred to depressive schemas, which consist of organised information stored in the long-term memory. In contrast to the psychodynamic view on depression, the schematic organisation of the clinically depressed individual under CBT is dominated by an overwhelming negativity and a negative cognitive triad is evident in the depressed individual's perception of the self, world and future. As, a result of these negative maladaptive schemas, the depressed person views himself as inadequate, deprived and worthless (Beck, 1976). Moreover, the term "cognitive triad" is utilised to refer to three elements of depressed person's negative view of himself or herself, the world and the future. Followers of behavioural and cognitive behavioural treatment models believe that depression is learned and then negatively reinforced because there are little or no positive reinforcements available to depressive individuals. As a result, behaviourist clinicians focus on positive reinforcement as a means of treating depressives (McLeod, 2006). Dysfunctional beliefs are embedded into the schemas and contribute to another basic concept referred to as cognitive distortion (Nelson-Jones, 2006). Beck's cognitive distortion model is widely utilised by cognitive behavioural therapists and perceptions are highly selective and often rigid when they perceive a situation as threatening and thereby causing impairment to the function of normal cognitive processing (McLeod, 2003). Therefore, with Clare and Jeremy it is imperative that a wider approach is considered particularly in light of the interaction of complex background factors in each case. Indeed, Beck further identified many different kinds of cognitive distortion including: arbitrary inference, selective abstraction, over-generalisation, magnification, minimisation and personalisation, which must be considered at the outset in approaching Jeremy and Clare's treatment (Beck, 1976; & McLeod, 2003). Beck further labels self criticism cognitive thoughts as "automatic thoughts", which he feels are the key to successful cognitive therapy. It is further recommended that the complex interrelationship of background factors in the cognitive processing of both Jeremy and Clare clearly lends itself to a consideration of these "automatic thoughts". Automatic thoughts symbolise scheme content, deeper beliefs and assumptions, which are less accessible to awareness (Nelson-Jones, 2006). Acquisition of schemas, automatic thoughts and cognitive distortions and associated vulnerability to psychological distress is caused by an interrelationship of multiple complex causal factors such as evolutionary, biological developmental and environmental. Many of these are common across various individuals however each person will have their own unique variation (Nelson-Jones, 2006), which is one of the primary strengths of this treatment model. With regard to Claire, it is evident that the background causal triggers are rooted in the sexual abuse she suffered in a child, which has informed behavioural patterns in her adult life. As such, CBT is arguably be better placed to address the interrelationship of complex causal factors contributing to Claire's anxiety. Indeed, Briere and Elliot highlight three stages of victim response in sexual abuse cases including: (1) initial posttraumatic stress, painful emotions, and cognitive distortions; (2) development of coping behaviours; and (3) long term consequence (1994). Briere and Elliot further suggest that after initial reactions to abuse, children begin to develop coping behaviour however these are not enough to overcome negative consequences of sexual abuse (1994). Briere & Runtz further suggest that there is strong evidence to highlight what they term as the "psychological toxicity" of childhood sexual victimisation"; which manifests in long-term damage (1994). Newmann et al, (1996) further highlight that female child sufferers of sexual abuse in particular have suffered from low self esteem, depression, disassociation, anxiety and post-traumatic stress disorder, which is clearly evident in Claire's situation. Briere further argues that the cognitive difficulties related to PTSD include impaired self esteem, negative self perception and numerous emotional after effects such as Claire's agoraphobia (1996). THERAPEUTIC GOALS OF TREATMENT Moreover the therapeutic goals of cognitive therapy are to revitalise the reality testing system and re-educate the client to adaptive meta-cognition, which is the ability to transform oneself and environment in order to effect a change (Nelson-Jones, 2006). This concept is central to the work of Ellis and Beck and researched in developmental psychology. Another goal in cognitive psychology is to enable the client to become their own therapist, by providing skills for problem solving for example. This will not only provide empathy with Clare and Jeremy's increased feeling of isolation from the outset, it will further facilitate therapy with regard to the complex background factors triggering their depression and anxiety. Ellis (1962) and Beck (1976) were clearly trailblazers triggering many other clinicians and writers with the cognitive behavioural model to further develop the approach to counselling (Grazebrook and Garland, 2005). Accordingly, the cognitive and behavioural therapy amalgamate the two elements of cognitive and behaviour. There are many facets to contemporary CBT however Grazebrook and Garland (2005) set out key features of it as based on scientific principles, which research has proven effective for a wide variety of psychological disorders (Grazebrook and Garland, 2005). A therapeutic relationship and common understanding is then built between client and counsellor to ascertain a shared view of problems through empathy to illicit client thoughts and behaviour (Kaplan & Saddock, 2007). This clearly facilitates an agreement of personalised and time limited therapy goals and strategies to make a long term change with the outcome of therapy being focused on specific psychological goals and skills through reflection and exploration of meaning attributed to the trigger event. On this basis, it is argued CBT is intrinsically empowering for the individual focused therapy model, enabling patient participation in employing their own resources. As such, the patient achieves satisfaction from accrediting improvement in their "automatic thoughts" to their own efforts (Grazebook and Garland, 2005). This has been further developed by Glasser's Reality Therapy model, which has two defined steps (Glasser, 2001). Firstly, Glasser's Reality Therapy model focuses on settling the counselling environment and stresses the need for counsellors to demonstrate an unconditional positive regard for their client (Glasser, 2001). Secondly, Glasser postulates the need to develop procedures that lead to change with the client determining what they want and what they are willing to do to achieve it. The practical application of Glasser's Reality Therapy further develops Beck's CBT model in applying a series of questions intended to induce the client into devising a plan of action going forward. Interlinked to this is the stepped care model of healthcare delivery, which originates from the US and is applied to a range of disorders, particularly of a chronic nature such as anxiety and depression (Williams & Martinez, 2008). The stepped care model has two key aspects: 1) The recommended treatment should be the least intensive of those currently available, but still likely to provide significant health gain. In the stepped care system, more intensive treatments are therefore reserved from the patients who do not benefit from a simpler first instance treatment intervention; 2) The functional purpose of Stepped care is to be self-correcting, in that the results of treatments and decisions regarding treatment provisions are monitored systematically, and changes are made, if current treatments doe not achieve significant health gain (Williams & Martinez, 2008). Moreover, Williams and Martinez refer to the fact the delivery of CBT in the UK has gone through two phases, whereby the first phase was limited to specialist practitioners and long waiting lists. The second phase has led to a growth of availability of CBT partly due to the stepped care model, which Williams and Martinez argue focuses on the issues the customer wants to tackled (Williams & Martinez, 2008). Indeed, Lovell and Richards further argue that the traditional service delivery systems in CBT services "pay little intention to the growing evidence base for brief and single strand-treatments over complex or multi-strand interventions" (Lovell & Richards 2000). On this basis, Lovell & Richards argue that CBT services should be centred on various levels of entry and service delivery under the stepped care model. The series of questions in Glasser's model have distinct parallels with Rogers' person centred therapy in seeking answers for why the patient wants to achieve a particular goal and what they are doing to achieve this goal. Glasser argues that Reality Therapy is intended to teach patients to accept control for their behaviour and aid self-evaluation of behavioural patterns (Glasser, 1984). Moreover, the central difference between Reality Therapy, Beck's CBT, and person centred therapy is the therapeutic relationship between counsellor and client, which in CBT is characterised by psycho-educational as opposed to medical (McLeod, 2003). Less attention is paid to the quality of the relationship and in CBT it is taken for granted that the relationship is necessary (Beck, 1976). Indeed, Beck highlights the therapist/patient alliance as being of central importance. However, Rogers' propounded six necessary conditions for therapeutic change suggests that Beck's emphasis on therapist genuineness and warmth does not bring significant therapeutic change (Woolfe and Dryden, 1996). Indeed, Merrett & Easton argue that part of the CBT problem "experiences arise because of the individual's active but often largely unconscious, thinking about challenging experiences, and that there are more or less universal ideas that everyone "with a problem engages in. if this is the case, then, when one individual aims to influence another in a therapeutic context, what is critical is the ideas that are communicated and received/used; clearly good relationship can underpin this process" (Merrett & Easton, (2006). Nevertheless, a welcome aspect of the CBT model is therapist/client rating scale (Bennun et al, 1986) where the client can rate the therapist on three factors, namely; positive regard/interest, activity/guidance, and competency interest. The positive regard is one of Carl Roger's "necessary" conditions, however Rogers believes that the self-concept element of CBT is clearly shaped by lack of unconditional acceptance in life. This is crucial in acknowledging the interrelationship between the two and acknowledging causality in CBT. To this end, Merett & Easton argue that the CBT model needs to be "based on an active model of psychological experience. This needs to include a focus on the descriptions and theories that a client has used to understand their experiences, rather than narrow concern with signs and symptoms". Indeed, the Beckian "inherent fragility" of both Jeremy and Clare suggest that in administering a CBT intervention, it is will be vital to approach the therapist/client relationship with caution and sensitivity. Ultimately, it is submitted that Beck's individual model paradigm of CBT is the most appropriate interventionist approach as a starting point for Jeremy and Clare's therapy going forward. As such, it is submitted that a halfway house between Beck and Glasser's model is likely to be the most appropriate in addressing Jeremy and Clare's treatment. CONCLUSION & ANALYSIS It is submitted that reliance on the cognitive per se (particularly in the Ellis sense) whilst involving the patient, is intrinsically limited by solely focusing on automatic thoughts and reactions to events, but arguably ignores the causality element, which clearly influences the cognitive. Additionally, Mulhauser argues that the crucial aspect of the rating scale is that the client is more likely to explore and express themselves without feeling they must earn positive regard from the therapist (Mulhauser, 2007). Conversely, CBT is less concerned with insight and relinquishes the endless search for past hurts and teaches the client how to prevent negative thoughts from creeping into their minds through set exercises and agendas (Gross, 2005). Whilst this directly addresses cognitives, it fails to address causality and the inherent weakness of compartmentalisation highlighted by psychodynamic theory (Nelson-Jones, 2006). Another central difference between the Beck and Rogers' approach is the less appreciation of the counsellor's self and impact on success of CBT as the approach permits confrontation and client challenge (McLeod, 2006). The basic premise of the approach is to alter the client's mindset, which results in a change of behaviour and feelings, when this is directed by the therapist rather than self directed as under Rogers' person centred approach (PCT). Moreover, there are recurring themes in CBT of management, control and monitoring, particularly from behavioural origins emphasising operant and classic conditioning (McLeod, 2006). An important task for early behaviourists was to discover how behaviour itself is learned. McLeod argues that this is due to concurrent growth of the US advertising industry and influence and the need to control consumer behaviour (2003). Contrastingly, the person centred therapy approach is based on the premise that the individual is their own best authority and the focus is on the basis of individual feelings and not counsellor judgment, challenge or categorisation (Mulhauser, 2007) such as Person's (1993) conceptualisation, which involves the counsellor devising a "mini-theory" of the client's problems (McLeod, 2003). PCT commonly does not give advise or interpretations as Rogers believed that people are trustworthy with a great potential for self-awareness and self-directed growth (Cooper, 2007). However, this clearly ignores the wider risk of compartmentalisation. Radically, Ellis claims that there are no legitimate reasons for a client to be upset or emotionally disturbed regardless of any psychological or verbal stimuli impinged on them, which is unequivocally undermined by psychodynamic research and clearly has concerning implications for the counsellor/patient relationship (Mulhauser, 2007). Person centred CBT or PCT clearly aim to focus on the client in devising a realistic framework for understanding their problems and setting targets, rather than the overriding goal of "fixing" people, which is implied by Ellis' theory (McLeod, 2006). The contrast of Beck's pragmatic concept of CBT further highlights the flaws of the Ellis model. The "Scientist-Practitioner" model (Barlow et al, 1984) stresses that therapists should integrate ideas of science with their practice, which through a wide variety of techniques will provide counsellors with a rewarding sense of competence and potency (McLeod, 2003). CBT further preserves respect for the value for research as opposed to the dogmatic model of Ellis. Alternatively PCT therapy is important in link between causality, however it has been suggested to risk counsellors avoiding evaluation tools on clients by categorisation through pre-defined diagnostic measures instead. Limitations of this are further highlighted by the NICE guidelines for mental health and behavioural conditions, little evidence of controlled research on person centred therapy (Cooper, 2007). Alternatively, limitation of CBT is that it is brief and time restricted and extremely structured in form, whereas PCT is long term, non-directive and client is the expert. The CBT model is effectively a problem/solution orientation and based on an educational model; without focusing on psychological causality and background. PCT could be considered simply problem focused, based on feelings and emotions rather than thoughts and behaviour. A sound therapeutic method is necessary but not entirely sufficient in CBT, in contrast to Rogers' claim of the relationship and unconditional positive regard being sufficient to provide therapeutic change (Cooper, 2007). Accordingly, it is submitted that with regard to the case studies, the factual scenarios point to depression in both cases with Clare additionally suffering from heightened anxiety. In line with the recommendations set out in the NICE guidelines, I feel that a CBT intervention would be the first point of recourse. However, the complex factors contributing to Clare and Jeremy's condition clearly undermines the suitability of Ellis' model and it is therefore submitted that a combination of Beck and Glasser's approach should be considered in ensuring empathy and direct involvement of Clare and Jeremy in the recovery process. As a concluding point, whilst the research clearly indicates the merits of the various forms of CBT, the importance of psychodynamic theory cannot be ignored in therapy models and it is submitted that the interrelationship between the multiple theories must be considered in improving therapy models going forward. BIBLIOGRAPHY A Alexandrovich & D, Wilson (1999). 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