Behavior Therapy is an Effective but Not Sufficient Factor in CBT - Essay Example

Behavior Therapy is an Effective but Not Sufficient Factor in CBT Introduction            Cognitive Behaviour Therapy (CBT) is a considered psychological intervention approach. It is variously understood to mean either the behaviour therapy alone or the Cognitive therapy alone or even a combination of the two therapies. However clear distinctions are to be made between the three concepts with the emphasis that CBT, as such, refers more pertinent to a pragmatic combination of the behaviour therapy and cognitive therapy with the patient situation in backdrop. Research literature has suggested that CBT is one of the leading orientations of psychotherapy (Roth & Fonagy, 2005) and in it one finds a rather unique class of psychological intervention as the entire therapy culls out and depends on a delicate balance of applying concepts both from the cognitive and behavioural psychological models of human behaviour .In fact there is such a wide variety of psychological models of human behaviour that CBT is considered to be a very fertile approach in tackling numerous situations needing intervention. Some instances of such models can be cited as theories of normal and abnormal development, and theories of emotion and psychopathology. In fact Fenton (2007) gives out a very understandable description of the entire concept of CBT by breaking it into member components of cognitive and behavioural therapies as follows,” Quite simply, cognitive-behavioral therapy or CBT is a combination of two kinds of therapy: cognitive and behavioral. In behavioral therapy, people learn how to change behavior. You may have already heard of the most common behavioral techniques used in the treatment of anxiety disorders: desensitization, relaxation and breathing exercises. Cognitive therapy focuses on thoughts, assumptions and beliefs. With cognitive therapy, people may learn to recognize and change faulty or maladaptive thinking patterns. Cognitive therapy is not about "positive thinking" in the sense that you must always think happy thoughts. It's a way to gain control over racing, repetitive thoughts which often feed or trigger anxiety. The two therapies often are used together because they are beneficial to each other. For example, in the midst of extreme anxiety, it may feel impossible to gain control over your thoughts and apply cognitive therapy techniques. Therefore, a behavioral technique such as deep breathing may help you calm down and focus on your thinking”. It is the latter argument of Fenton which is the focus of this paper. This paper essentially looks into exploring the argument that behaviour therapy is an effective approach with in the CBT but it is not the only and sufficient approach. The paper looks into the concepts of cognitive and behaviour therapies in depth and the possible and more effective applications of the CBT,when the two are combined. The paper also discusses some other approaches which are finding application under the umbrella of the CBT. Cognitive Concepts and Therapy The initial questions that arise in cognitive approach are conceptual. They relate to what are the various levels of cognition that is accorded importance in literature. In the 1960's, Aaron Beck, developed his approach called Cognitive Therapy.  Beck's cognitive therapy was particularly found very useful in the effective treatment of depression and related symptoms. Beck and his associates reckon three identifiable levels of cognition that are pertinent as treatment milestones as cognitive approaches are applied to within the overall approach of f CBT.These three levels of cognition are : full consciousness, automatic thoughts, and schemas (Clark et al,1999). Within these three levels the highest level is consciousness and it is defined to include the mental state in which rational decisions are made with full awareness of the decision maker. Decision maker is rationally opting to choose the way he finally did and he has rational arguments to justify his acts. Automatic thoughts, on the other hand, are spontaneous and emerge in a automatic train and can be more pertinently called private set of cognitions. These thoughts often occur in a swift and rapid stream like state encourse daily lives and the thinker may not necessarily examine such thoughts for being accurate, meaningful or of any value in decision making .owing to volume and speed of such thoughts they are invariably not subject to any sort of assessment-either for accuracy or contextual relevance. Instance of automatic thought patterns can be found most commonly in isolated individuals who are secluded from mainstream society and lack interaction with people. Living alone can give them an opportunity to replay thoughts relating to past events; in addition they can develop thought streams pertaining to insecurity associated with living alone and ,in fact they do also develop so many automatic thoughts regarding planning an opportunity to mix with society until unless they suffered from agoraphobia and choose to live in seclusion. It is accepted that automatic thoughts are normal in most persons; however in conditions that warrant therapeutic interventions such as clinical states of depression and anxiety disorders, these automatic cognitions are invariably comprised of several errors in logic and inter linkages (Wright et al,2003;Beck et al,1979). For instance depression states are predominated by automatic thoughts pertaining to lack of effectiveness and impotency to obtain solutions to problems with an overall milieu of automatic thoughts that pertain to low self-esteem and negativity. Whereas in anxiety related clinical states, automatic cognitive thoughts invariably work to assess unrealistic targets, on the one hand, and on he other assess the associated risks with such targets way excessively and the reduced anxiety argument in substratum often relates to a fear of inability to manage with deep under estimation of the abilities available.(Wright et al,2003) Some examples of clinical state automatic thought patterns are “I should be doing better in life; I’ve let him/her down; I always keep messing things up; It’s too much for me; I can’t handle it; I don’t have much of a future; Things are out of control; I feel like giving up; I’ll never be able to get this done; Something bad is sure to happen etc.(Wright et al,2004)Schemas are best reckoned as core beliefs. This is the most ingrained level of cognitive thoughts and is comprised of some kind of localized fundamental rules or applicable templates for information processing that needs to be done during the course of everyday lives. These fundamental rules are a kind of a constitution for a person and also like a constitution they are amenable to moulding and are shaping by life experiences and other radical events that leave impressions. Some instances of recurring clinical state schema statements can e given as follows:” I must be perfect to be accepted; I’m a fake; If I choose to do something, I must succeed; I’m unlovable; No matter what I do, I won’t succeed; The world is too frightening for me; Others can’t be trusted; I must always be in control; I’m stupid; Other people will take advantage of me etc. (Wright et al, 2004).Since these schemas are fundamental and core values that an individual holds for day to day information processing these find a substantial application in cognitive therapies applied with in the CBT fold. This is because of the fact that moulding, altering, fine tuning or even over turning these schemas can bring about vast improvements in event cognitions. In fact self worth and coping behaviour improves vastly with appropriate interventions in schemas held. The schemas have another major application in that a timely intervention involving schemas can also work as effective recurrent to relapsing behaviour as pat of an ongoing therapy which may involve other approaches like behaviour therapy. Various cognitive methods used in CBT include, Socratic questioning, guided discovery, examining the evidence, Examining advantages and disadvantages, Identifying cognitive errors, thought change records, generating rational alternatives imagery, role play and rehearsal.Questionng is the most frequently deployed method. This helps the subject to uncover various facets of his/her thinking revealing the dysfunctional and maladaptive portions that were stuck in the thought process. Questioning also helps in providing a new and fresh perspective to the subject in that the maladaptive portions are rebuilt, attacked and reformed. Two types of questioning methods are deployed. One is Socratic questioning which involves posing guiding questions that helps the subject’s involvement in discovering answers. Other is the guided discovery method wherein a series of questions are posed that helps the patient to explore and reform the dysfunctional and defective cognitive processes. Both methods deploy specific techniques as part of therapeutic sessions, for instance, guided discovery deploys the examination of the evidence exercises and two-column analyses of the pros and cons of maintaining a fundamental and core belief. Other cognitive techniques like imagery, role play, rehearsal exercises, and homework assignments work on the principle of replicating dysfunctional cognitive process along side its outcomes for the subject(s) to view and assimilate. Role play, for instance, may involve the subject himself. The subjects gain insights into these dysfunctional models and stand to correct their own dysfunctional cognitive process usually after some more therapy sessions exemplifying and clarifying the significance of techniques and their outcomes. At the other spectrum of the cognitive methods used within the ambit of CBT is the thought change record. Essentially this method comprises in letting the subject record his own notes on his cognitive process, say automatic thoughts, and also record associated emotions alongside such thoughts. This is normally resorted to when the patient or the subject has just been introduced to therapy sessions. After this familiarization with the process of recording his thoughts and associated emotions the patients may be advanced to the stage where they may be administered a full five-column thought change record wherein the subject would identify the cognitive errors in automatic thoughts, generate rational alternatives thereupon, and even chart the progress or outcomes of making these changes (Beck et al, 1979). Behaviour Concepts and Therapy Behaviour therapies stand at the outcome spectrum of the CBT as theses therapies not only address the behavioural input requirements of the subjects and hence become more visible to subjects but also the role of these therapies in essential renforcement,activation and maintenance of behaviour patterns also provide them additional visibility and credibility. Cognitive therapies are often side tacked in these phases of treatment as having served their purpose of reconstructing the inner thought process o the patients. However behavioural concepts precede the development of the cognitive contents of he CBT and they had been exclusively deployed for long under the terminology of behavioural therapies. Such a stand alone status and the present status of the behavioural therapies, with in the CBT, is informed of several behavioural concepts and techniques which were derived from observation and essentially empirically. As of date these behavioural concepts find a hybrid reorganization with cognitive concepts in the CBT.Some of these important concepts are as follows: Behaviour states typical of various degrees of depression which includes conditions like feeling weak and lacking energy or having low energy, lacking motivation or complete lack of interest, feeling of impotency or helplessness, and other notable down grading of psychomotor activity, could be propped up sufficiently and reformed with the deployment of behavioral techniques; in particular, exposure therapy and all encompassing methods and techniques within exposure therapy result in substantial improvements in clinical states associated with anxiety disorders and, lastly, the behavioral therapies are of a great significance in upgrading the coping abilities of the subject apart from the social and problem solving skills(Wright et al,2006; Meichenbaum,1977;Marks et al,1993) As has been stated above, presently the behavioural therapy find very useful application within several CBT protocols ,say for depression, in the form of deployment of techniques like activity scheduling and graded task assignments to prevent relapse of the subject into defective cognitive process and these behavioural techniques also help subjects reactivate their behaviour pattern. Ultimate target of such behavioural therapies is to keep the subject on track and develop a steady normal behaviour pattern. Similarly almost all CBT protocols for anxiety disorders deploy techniques like exposure and response prevention to check the avoidance infested behaviours of the subjects. In the absence of these interventions the subjects would have comfortably relapsed into their clinical states and would have retracted further in a cocoon quite desensitized from their physiological symptoms of anxiety. Various behavioural methods used in CBT include activity and pleasant event scheduling; graded task assignments; exposure and response prevention; relaxation training; breathing training; coping cards and rehearsal. Activity and pleasant event scheduling are commonly used to help depressed patients reverse problems with low energy and anhedonia. The focus of all of these techniques involve the activities undertaken by subjects, problems encountered by subjects during ordinary day to day life with specific background on the events and issues which have caused the clinical state. At the start of behaviour therapy sessions a schemata of day’s or week’s activities are obtained. In pleasant events’ scheduling, for instance, pleasant activities are presented and the subject is required to rate such activities on his/her degrees of accomplishment and/or pleasure derived from such activities. Thereafter based on this data the therapy enter the core collaborative mode wherein the patient and the therapist combine together to initiate and design changes so as to raise activity level of the subject, result in greater sense of belongingness and pleasure in the activities. A primary target is to remove any social isolation of the subject and help him overcome any procrastination tendencies that may be harboured in respect of event participation or maintaining a newly ordered schedule. Graded task assignments, involve breaking encountered problems into parts and develop a linked and graduated problem management is developed. This technique is generally deployed in situations where the patient encounters challenging situations resulting in self defeating thought like, ‘I cannot do it, this is not for me’ etc. Hierarchical exposure to feared stimuli, relaxation training, and breathing training are most effectively deployed in the treatment anxiety clinical states. Exposure protocols come in two variants i.e. either rapid or gradual. A hierarchy of exposure experiences involves presenting the subject with situations that give rise to sequential increases in the degree of anxiety aroused. Subjects go through the sequential process and they arrive at the point where anxieties disappear or vanish and they feel relaxed and in control. This helps subjects get habituated to anxiety streams and even understand the process of self dissipation of the anxiety factors. Other techniques like progressive relaxation and breathing exercises are typically deployed to control the excessive levels of autonomic arousal subjects may feel in confusing and challenging situations .These techniques are also used as supplementary techniques with in the exposure protocol. However standalone applications in dealing with panics and anxiety are widespread as well. Coping cards, are very useful in forming strategy in dealing with specific real life events that cause anxiety, panic or even depression. Examples of such events may be arrival of an overbearing boss, attendance in a regular feature meeting where subject is put in pressure for results, nagging spouse or even suicidal tendencies. In this technique distilled and collaborated coping methods and tips are recorded on small coping cards. First these cards are practiced and rehearsed in therapy settings letting the patient know the significance and use of coping cards. Then the coping cards are released for real life application. It may be possible that some of the coping techniques may require revisions and subsequent therapies would help achieve that. From the above description of behavioural therapies it is abundantly clear that behavioural therapies play a critical role in, preventing relapsation,reactivation of subjects and in maintenance of the cognitive therapy corrected cognitive thought process apart from developing and reinforcing the normal behaviour patterns; however its is also clear that behaviour therapies would only be half approach without understanding the cognitive and internal thought process to external stimuli of the subjects. Thus while behaviour therapies are very effective within the CBT they do not form a sufficient approach.A comprehensive and sufficient approach is to be found in CBT. The combined Approach to CBT and more The fact that cognitive and behavioural therapies have a close linkage is established by the fact if one looks at the evolution of cognitive therapies. Literature is unambiguous in tracing the cognitive school to the thought provoking conceptualization and theoretical ideas of Beck (1970) and Ellis (1962) into popular therapeutic methods. Since then cognitive approach has become fertile and rich with many cognition based therapies proliferating, with a good number of them explicitly building on and drawing on treatment components deployed in behavior therapies. An immediate outcome of the gelling of the two approaches-behavioural and cognitive- was the emergence of the CBT as a terminology( Kendall & Hollon, 1979; Meichenbaum, 1977). The development in deriving various permutations and combinations of the cognitive and behavioural therapies within the overall ambit of the CBT has been so vigorous and robust that the CBT has come to address issues on a very wide canvas and have been deployed in treatment of a host of clinical states. Such clinical conditions include treatment of depression (Taylor & Marshall, 1977),' anxiety ( Meichenbaum, 1972), phobias ( Odom, Nelson, & Wein, 1978), headaches (Holroyd, Andrasik, & Westbrook, 1977), assertiveness problems ( Craighead, 1979), and numerous other disorders. A very clear definition of CBT as a comprehensive approach gelling the behavioural and cognitive therapies is proved by Grazebrook et al(2005) as follows:” Cognitive and/or behavioural psychotherapies (CBP) are psychological approaches based on scientific principles and which research has shown to be effective for a wide range of problems. Clients and therapists work together, once a therapeutic alliance has been formed, to identify and understand problems in terms of the relationship between thoughts, feelings and behaviour. The approach usually focuses on difficulties in the here and now, and relies on the therapist and client developing a shared view of the individual’s problem. This then leads to identification of personalised, usually time limited therapy goals and strategies which are continually monitored and evaluated. The treatments are inherently empowering in nature, the outcome being to focus on specific psychological and practical skills (e.g. in reflecting on and exploring the meaning attributed to events and situations and reevaluation of those meanings) aimed at enabling the client to tackle their problems by harnessing their own resources. The acquisition and utilisation of such skills is seen as the main goal, and the active component in promoting change with an emphasis on putting what has been learned into practice between sessions (“homework”). Thus the overall aim is for the individual to attribute improvement in their problems to their own efforts, in collaboration with the psychotherapist. Cognitive and/or behavioural psychotherapists work with individuals, families and groups. The approaches can be used to help anyone irrespective of ability, culture, race, gender or sexual preference. Cognitive and/or behavioural psychotherapies can be used on their own or in conjunction with medication, depending on the severity or nature of each client’s problem”. The effectiveness and efficiency of CBT over other approaches has been long a question of heated debate. Some literature has placed the issue in right perspective. It is beneficial to cite that literature here as the citation also works to put behavioural therapies in the right perspective in the sense that it indicates clearly that such therapies are only a part and parcel of the overall approach which came to be termed as CBT.Miller & Berman(1983) state as follows on the issue,” Twenty years ago the advent of behavior therapy was heralded by impressive claims of effectiveness, claims that even its proponents now admit sometimes outstripped the available research evidence. Now cognitive behavior therapies may be riding a similar wave of initial enthusiasm. Judging by the increasing number of books and articles that either advocate or examine this type of treatment, cognitive behavior therapies appear to have captured the interest of numerous clinicians and researchers. Coupled with this popularity is the growing conviction that cognitive behavior therapies are an especially effective form of treatment. As our review of the research evidence confirms, these therapies do indeed bring relief to a broad range of patients. Yet, despite clear evidence that cognitive behavior therapies are more effective than no treatment, there is little evidence that they are more effective than other widely practiced psychotherapies”. In fact CBT has such a vibrant, interactive and collaborative approach that is has been instrumental in reengineering the definition of the word therapy. The empirical based and number based formula development and creation that was resorted to in early 1980s to mid 1990s had resulted in lot of discredit coming to psychotherapy’s approach to handling patients. Some leading psychotherapists have aired their view both from the vantage point of views of practitioners and policy contributors on the matter. An effective presentation was made by Grawe (1997) who warned that the empirically validated obsession may appear to end in a better psychotherapy delivery system in the sense of reducing such treatment to exact prescriptions which are formula and techniques based apart from bringing in more patients turnover; however this would never amount to a better psychotherapy. Even for practitioners these quick and simplistic techniques might be easy to learn and make the pedagogy technical and easy but the fact will remain that they would address only a very limited spectrum of symptoms which is- as much as is covered by their small empirical data and testing. And if these empirical data and techniques are based on validation of an unrepresentative sample of studies and with a biased population of clients, then the treatment would be a waste of time.CBT, in contrast, makes for a contextual treatment which is collaborative and interactive. At start of treatment spectrum we have the cognitive approach and at the end of the spectrum we have the behavioural approaches. Conclusion In conclusion one can see the vast array of the concepts, methods and techniques covered by the two therapies i.e. the behaviour therapy and the cognitive therapy and the clear distinction that both of these address different aspects of dysfunctional human behaviour and that techniques under both therapies can be deployed in tandem to result in a comprehensive and non relapsing treatment of various clinical states and dysfunctionalities.The combined approach is adopted within the realm of CBT, as has been noted above. The CBT works on the assumption that negative automatic thoughts and pervasive beliefs when combined with self defeating behaviour results in formation of the various degrees of depressive states. CBT also emphasizes clearly that behaviour therapy methods and techniques are not sufficient on stand alone basis to treat clinical states as the behaviour therapies does not devote attention to the fact that learned thought patterns and beliefs, all quite internal to a subject, considerably affect such subject’s actions, feelings and behaviour.Thus resorting to simply behavioural therapy approaches in clinical states would amount to reaching the other shore of the river without using the nearby convenient bridge. This underpins the fact that the other shore, could still be reached by other means like swimming, boat etc; however it would involve more efforts and costs and would be a solution which cannot be resorted to recurrently when the convenient bridge is present. The bridge simile fits cognitive approach as the cognitive approach helps subjects identify the thoughts that trigger mood undulations and helps in replacement of underlying unrealistic and dysfunctional beliefs with those that are more realistic and functional.Behavioural therapy picks on the cue from where the cognitive therapy ended and helps the patient develop and strengthen new behavioural patterns based on rationalized thought patterns and new found realistic and functional beliefs o schema. Cognitive approach and now other methods, such as multimedia based approaches, provide that essential bridge which is becoming broader and smoother as research brings in more vistas within the fold of a rather holistic CBT. References Roth A., and Fonagy P. (2005) What Works for Whom: A critical review of psychotherapy research. Second Edition. The Guildford Press, London. Fenton, Cathleen Henning. (2007). 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