3.1 Introduction
CBT comes in many different forms.
In this module, you will have the
chance to learn about three approaches that are closely related to -yet
distinct from - traditional CBT.Each has its own philosophy and set of
interventions. Some therapists may choose to draw upon only one of these
paradigms. However, it is common for practitioners to base their choice of
techniquesnot on an allegiance to any one paradigm or 'school', but instead on
the immediate needs of their client. You will learn about Acceptance
and Commitment Therapy (ACT), Behavioural Therapy (BT) and Cognitive
Analytic Therapy (CAT).
3.2 What is Acceptance and Commitment Therapy (ACT)?
ACT is similar to mainstream CBT in that it outlines how feelings, thoughts and behaviours interact to create or maintain maladaptive approaches to life.However, there is one key difference. Mainstream CBT assumes that it is possible to challenge and restructure negative thoughts and that the key to enhanced psychological wellbeing is to change how one thinks. ACT is built on the premise that it is a person's reaction to their thoughts and feelings that ultimately makes a difference, not their reaction to external events.
An example may help explain the difference Let's suppose that a student studies hard for an exam, but receives a low mark. The student thinks,“I'm so stupid”. As a result, they feel angry at themselves and experience a significant drop in mood. In the CBT paradigm, this situation would be interpreted as proof that the student needs to examine their underlying beliefs, which might include “I have to be good at everything all the time”, or “If you fail at something, it means you are always going to be a failure”. The student's CBT therapist would also help them see that they are engaging in overgeneralisation, i.e. they are jumping to a negative conclusion based on a single adverse event.
Although there are several ways a CBT therapist might tackle the issue, it is likely that they would ask the client to write down alternative ways of looking at the situation. The client may be asked to think about evidence that goes against their negative interpretation and to keep a thought diary in which they record their negative thoughts, the extent to which they believe them to be true and how they could reframe negative events.
On the other hand, an ACT therapist would encourage the student to identify what they are feeling, but then learn how to move on from the negative emotions. The therapist would invite the student to sit with their anger and sadness. They would then ask what the student could do next and whether their proposed actions would fit in with their personal values and life goals.
For instance
The student might say that they value education highly and that their most important goal at this point in their life is to graduate from university with a good degree. Both parties could then decide on the solutions open to the student, from changing their study approach to getting extra help from a private tutor. Whichever path the student takes, the therapist will emphasise the importance of acting according to their own personal values.
3.3 Principles and Techniques Used by ACT therapists
ACT can be thought of as CBT with an existential twist, although there are many possible definitions. Even those who practise ACT admit that it is hard to describe the underlying principles. Writing in the journal Psychotherapy In Australia, therapist Russell Harris writes that ACT is “so hard to classify that it has been described as an 'existential humanistic cognitive behavioural therapy'”. He later describes it as an “eclectic mix of metaphor, paradox and mindfulness skills, along with a wide range of experiential exercises and values-driven behavioural interventions”. He sums up ACT using the motto, “Embrace your demons and follow your heart”.
There are six core principles of ACT.They are all intended to help a client become a conscious, mindful individual with the ability to adapt their behaviours to suit their circumstances. This is known as psychological flexibility. They are not methods that will help a client or therapist treat a diagnosed problem, but should be thought of as aset of positive skills. The six core principles are detailed below:
Acceptance
Feelings are not to be pushed away and unhelpful thoughts do not need to be challenged head-on. Instead, they are an inevitable and normal part of being human. They should be acknowledged, but there is no need to fight them.
Cognitive defusion
This skill entails being able to separate self and feelings. People with mental health problems tend to get caught up in their thoughts and as a result, begin to feel as though these thoughts and feelings define them.
For instance
Someone who frequently feels sad or depressed may come to believe “I am sad”, or “I am a depressed person”. This self-labelling can cause a considerable amount of distress. Then, to make matters worse, someone in this position will typically try to reason with their thoughts and fight against them instead of letting them come and go.
Being present
To be present is to live in a mindful way. Mindfulness entails noticing what is going on in the moment, rather than worrying about the future or ruminating about the past. Mindfulness can be practised in many different ways. Such practises can be as simple as taking a few minutes to notice your thoughts and feelings, choosing to let them drift past like clouds in the sky or move past you like cars on a busy road. Another popular practise is 'thought labelling'.
Mindfulness does not entail 'thinking of nothing'. Rather, it entails accepting everything. When an individual stops over-analysing and judging events going on all around them, they become less anxious and instead make conscious decisions that allow them to act with psychologicalflexibility.
Self as context
When someone views their 'self' as 'context', it means that they are capable of stepping back from an emotion or event and are willing to realise that they can observe it happening without necessarily becoming caught up in it.
Values
In the ACT paradigm, a person's life is most meaningful when they behave in accordance with their values. Whether they realise it or not, everyone has a set of values. For a variety of reasons, people sometimes drift away from their values. According to the ACT principles, the greater the gap between a person's core self and their behaviours, the more likely they are to experience hopelessness and general psychological distress. Therapists frequently meet clients who live in accordance with someone else's values.
For example
If their parents value financial success and educational attainment, a client may have unquestioningly adopted these values as their own. A turning point in the change process is triggered when a client starts to decide what their personal values are, rather than adopting those of others in their life.
Committed action
ACT is pronounced “act”, partly to emphasise the role that proactive behaviour plays in the change process. ACT therapists encourage their clients to work out their next steps based on a set of identified values. These values do not have to remain static over time, but they need to be sufficiently consistent that a client can use them as a meaningful foundation on which to build their lives.
3.4 Relational Frame Theory (RFT)
Although B.F. Skinner and other influential figures in the behaviourist movement contributed a great deal of knowledge to our understanding of human and animal behaviour, they could not provide a comprehensive outline of how language 'works'. Although pushing buttons, pulling levers and basic building blocks of human relationships can be explained with reference to theories of conditioning, language is much more complicated.
RFT is a theory that builds on the behaviourist tradition and is used in the ACT paradigm to explain the relationship between language and emotions in humans. Several key figures played a role in its development, including psychologist Dr Steven C. Hayes. The behaviourists established the principles of operant and classical conditioning in both humans and animals, but there are important differences (and implications) between the two.
For example
If a pet owner says “Biscuit!” before giving their dog a biscuit, the dog will soon start to get excited whenever “Biscuit!” is called. However, if a pet owner gives their dog a biscuit, but says “Biscuit!” afterwards, instead of before delivering it, the dog will not form a connection between the word and a treat. On the other hand, if this experiment were to be repeated with a human child, the connection would be quickly established.
Even if a parent waited a full minute after the child had finished eating before exclaiming “biscuit!”, the child would probably still expect to receive one in the future upon hearing the word. Human beings are unique in that they can form relationships between apparently neutral events that have not actually predicted other occurrences on previous occasions. To put it another way, only people - not animals - can form these bi-directional relationships. Human beings are also alone in being able to form new associations based on abstract ideas and stimuli.
For instance
If a boy is told, “You just had some aubergine and it's known as an eggplant in some places”, he will respond to “eggplant” in the same way as “aubergine” in the future. He will think of aubergines as both a kind of physical object and a term that denotes aubergines. This natural human ability to make quick links between words (whether spoken or 'heard' internally) starts early in life, when a child is taught to label their experiences, abstract ideas and objects.
How do humans develop this ability?
During the first year or so in a baby's life, their parents or carers will start to teach them how to name objects around them.
For example
A father might show a spoon to his daughter and say, “That's a spoon! Where's the spoon? That's right, there's the spoon!” He is showing the item to his child, naming it and asking her to point to it when he says the word. This exercise instils a bi-directional relationship - he is explicitly linking the spoon with the word “spoon” and vice versa. However, if his daughter were a little older, he would only say “That's a spoon!” He would not need to say anything else, because his child would already understand how to fill in the blanks. She would already know how to formulate the reverse relationship. When a child grasps this concept, they will start using names of objects when making requests, e.g. “Want spoon!” She has formed a “relational frame” - a piece of knowledge that allows her to effortlessly use her past experiences to draw new inferences and relationships between labels and new items.
If a child is taught the concept of 'bigger than', they are then able to answer any number of questions that utilise this concept, even when the situation and objects under discussion are different. They will be able to respond to both “Is this coat bigger than that coat?” or “Is this dog bigger than that dog?” Other relational frames include 'Closer and further', 'Earlier and later' and 'Faster and slower'.
Fact
Between the ages of 16 and 23 months, a child will acquire one or two new words every day.
Source: www.pbs.org
RFT and mental wellbeing
In general, the human ability to derive relationships based on a minimal level of experience and training is a huge advantage.
For example
This capacity has allowed us to work out mathematical equations and to undertake scientific research. Our capacity to make complex inferences has allowed us to develop close, meaningful relationships and culture. We can form symbolic relationships, which allow us to communicate substantial amounts of information quickly. On the other hand, there are disadvantages. Because human beings are so good at forming relationships between actual events, descriptive words, memories and imagined future scenarios, they are liable to induce unnecessary distress.
For example
Someone with a fear of spiders might become just as distressed when reading about spiders as they would when encountering a live specimen. Trying to fight feelings with words and logic - to try to reason one's way out - just invites more problems, because the feelings become even more entwined with particular words and abstract ideas. Therefore, the most rational response is to accept feelings instead. This is why ACT therapists encourage mindfulness.
Metaphors and similes
ACT practitioners often use metaphorical language to communicate with their clients. This is because concepts such as mindfulness and 'the self as context' can seem alien to those who have received no formal training in psychology or counselling. Engaging language also helps clients remember the underlying message.
For example
An ACT therapist might use the quicksand metaphor when telling a client about the value of accepting thoughts and feelings instead of fighting them. When a person falls into quicksand, they will soon become submerged and drown if they try to get out. When they relax and spread out their body weight, they will float instead of drown. In a similar fashion, those who accept their thoughts and feelings will be able to float through them rather than become bogged down in their distress.
The role of diagnoses and symptoms in ACT
ACT does not aim to eliminate psychiatric symptoms. Instead, the end goal is to help the client create and live a meaningful life that fits with their personal dreams and wishes. ACT practitioners do not assume that diagnostic criteria are helpful. In fact, they believe that when personal experiences such as feeling low or paranoid are labelled as 'symptoms' the client's suffering is increased, because they have been made to feel as though their personal experiences and very essence of who they are is pathological.
The ACT paradigm challenges the notion that human beings are, by default, contented and well- balanced. They argue that most people have ups and downs and a significant proportion of the population will meet the criteria for at least one mental illness at some point in their lives. Therefore, this so-called abnormality may very well be normal, and the goal of both therapists and clients should be to forge a meaningful life in which all feelings are accepted and tolerated.
How does ACT help clients?
ACT allows clients to learn first-hand that all feelings are transient and that no negative emotion lasts forever. This can provide them with some immediate breathing room and instils a sense of hope for positive change. ACT provides clients with practical skills that enable them to handle difficult feelings and situations that will arise in the future. The therapeutic alliance rests on equality. ACT therapists are always ready to point out that no one has a perfect life and that even experienced therapists are forever in a state of changing and learning.
3.5 What is Behavioural Therapy (BT)?
As its name suggests, the purpose of BT is to eliminate harmful or undesirable behaviour. BT is appropriate for clients with mental health problems that result in unwanted actions, such as the compulsive rituals seen in OCD. Practitioners consider the past as a useful source of information, because it contains clues that help them understand how and why a client's maladaptive behaviours began.
However, BT does not entail in-depth analysis of a client's history. The primary emphasis is on the present. CBT is a form of BT, but not all BT resembles CBT. The premise of all BT interventions is that behaviour is learned and, therefore, can be un-learned. BT practitioners draw on two key ideas - classical and operant conditioning.
3.6 Classical Conditioning
Interventions based on classical conditioning include the following.
Systematic desensitisation
The first step is to create a list of feared situations that cause the client to feel anxious.
For example
If a person is afraid of spiders, their most feared situation might be finding a large spider in their bedroom, whereas their least feared spider-related situation might be to look at a photo of a spider. These situations can then be arranged to form a hierarchy of fear, in which the least feared situation is at the bottom and the most feared is at the top. At each stage, the therapist will help the client enter a state of relaxation.
For instance, in this example, the therapist would help the client relax as they looked at a photo of a spider. This would then create an association between feelings of calm and the stimulus. Eventually, the client would be able to pair positive feelings with even their most feared spider situation.
Flooding
When a therapist uses a flooding technique, they subject the client to their most feared situation. In the spider example, placing a live spider on the client's hand with little prior preparation would constitute flooding. The client will then remain in the situation for as long as it takes for the fear to subside. When the client is forced to confront their fear head-on, they learn that nothing bad will happen.
Flooding can eradicate a phobia quickly, although it must be used with caution. Highly sensitive clients may find the process unbearable and might even want to leave therapy if they receive inadequate support.
Aversion therapy
When an individual is conditioned to associate their undesirable behaviour with an unpleasant physical sensation such as nausea, they will be in a better position to refrain from engaging in such behaviour in the future.
For example
A person who has a problem controlling their drinking might be given a drug that produces feelings of nausea when it interacts with alcohol. The subsequent sickness can make them less inclined to ingest alcohol in the future.
Activity: Aversion Therapy
Estimated time: 5+ minutes
Imagine that you have been asked to devise an aversion therapy intervention for someone who is addicted to playing video games.
What would you suggest?
3.7 Operant Conditioning
Interventions based on operant conditioning include the following.
Extinction
When any and all reinforcements are removed, this is known as “extinction”.
For instance
If a teenager is prone to causing disruption in class, extinction may consist of removing them from their peer group (who might be giving them the attention they crave) and forcing them to work in isolation for a set period of time. When the reward is no longer gained as a result of engaging in the behaviour, the incentive is gone.
Modelling
Social learning theory posits that people pick up behaviours from those around them, particularly if the behaviour yields a positive return for the role model.
For instance
If a child's mother or father shouts as a means of getting their own way, the child will learn that they too stand a good chance of having their desires met if they behave in an aggressive fashion. Positive role models can correct bad or undesirable behaviour. In a therapy context, the role model might be someone the client already knows or it may be the therapist.
Contingency management
This is a more formal approach. A therapist and client will draw up a contract that states the undesirable behaviours that need to be eliminated, together with the rewards and penalties to be used. For some clients, a signed contract offers a sense of mutual partnership and accountability.
Token economies
Popular with parents, teachers and those managing institutions housing people with severe behavioural difficulties, a token economy relies on positive reinforcement. When an individual demonstrates good behaviour, they receive a token or privilege.
Activity: Token Economies
Estimated time: 5+ minutes
Imagine that you have been asked to help a teacher plan a token economy intervention for a small class of primary school children with behavioural difficulties.
What kind of intervention would you include in your plan and why?
3.8 What is Cognitive Analytic Therapy (CAT)?
CAT aims to bridge the gap between mainstream CBT and behavioural approaches and ideas from psychoanalysis. CAT is a collaborative approach that takes into account the client's past history, its effect on current behaviours and how positive practices might be reinforced in the future. CAT is an integration of unique, solution-focused methods and is tailored to each client's requirement. CAT is delivered in one-hour blocks, at the rate of one per week, from 16 to 24 weeks.
It can be delivered to individuals, couples and groups. CAT sessions help the client understand their past in terms of the effect on their feelings, emotions and thoughts. The client is actively involved in their own healing and decide the goals and solutions that they want to be involved with.
Main Tenets of CAT:
During the first 4-5 sessions, the therapist and client understand how the client has tried to deal with their feelings and if they have been 'labelling' their feelings .Practitioners keep the jargon simple and the client chooses the language he or she wants to discuss their life-story.The client exercises their choices every step of the way to the issues they need interventions for, the type of solution that works best for them and what they want from their therapy .CAT helps clients identify negative relational patterns that have negatively impacted their feelings and The goal of CAT is to introduce new self-awareness which the client can use to improve their wellbeing and solve their problems.
One of the unique features of CAT is that it recognises the effects of social deprivation and injustice on mental health. Its founder, Anthony Ryle, was a doctor working in inner-city London during the 1980s. He realised that there was a desperate need for a relatively short-term yet holistic form of psychotherapy that could be used with a range of patient groups (including those with learning disabilities). This is a point of difference between CAT and CBT, as the latter tends to address an individual's problems without addressing the broader context.
The therapeutic alliance is key to the success of a CAT intervention. CAT practitioners are keenly aware that clients often fail to engage with the therapy, miss sessions, or experience a dip in motivation. Therefore, it is important to build a strong, trust-based relationship, as soon as possible. Relationships with other people in the client's life are a key focus of CAT, as they play a large role in determining a client's quality of life.
For example
If a client often finds themselves in situations where another person takes advantage of them, this may well be because they learned early on in life that their needs are secondary to those of everyone else. As a result, they might have come to believe that they should always obey instructions and agree with whatever another person says, even if it comes at a personal cost to their wellbeing. This pattern could then cause the client a considerable amount of distress.
CAT provides a means of experimenting with new relationship habits, such as assertive communication. Whereas CBT is often delivered in a highly structured format, using readymade protocols or techniques tailored to specific diagnoses, CAT therapists adopt a more flexible approach that places less emphasis on labelling a client's problems and more on understanding their past. This is especially useful for people with complex mental health problems, or those who have suffered trauma.
3.9 Traps, Snags and Dilemmas
CAT pioneer Anthony Ryle noticed that his patients exhibited many common patterns that kept them trapped in dysfunctional relationship habits - both in terms of their relationships with themselves and their relationships with other people. These patterns fall into three categories.
Traps
These are vicious cycles of behaviour that an individual reinforces. These cycles have been in motion for so long that they feel 'normal' and 'right', even if the individual feels miserable.
For example
Someone who believes that anger is bad and that they are a bad person for showing their anger might actually end up displaying a great deal of anger as a result of trying to suppress their rage. They will then feel bad about themselves and their behaviour will be stronger because it has been reinforced.
Snags
These are combinations - which may be quite elaborate - of assumptions, feelings and thought patterns that result in someone retreating from something (or someone) that they would like. Someone caught in a snag will typically feel guilty and undeserving of anything “good”.
For example
Someone might decide to change, but then fail to follow through on their plans because they suspect other people may not like the 'new person' they are becoming. This leads to further negativity and so the cycle continues.
Dilemmas
Dilemmas are self-imposed dichotomies that cause an individual to feel as though there is no easy solution to their problem. They may need to change their perspective, yet be unwilling or unable to do so.
For example
Someone might think that if they are upset, the only options they have are to explode with rage or to suppress their feelings. There is seldom any logical reason behind these dilemmas - they often have roots in past experiences, or may have been modelled by parents or carers. Over the course of therapy, a CAT practitioner will do the following:Allow the client to tell their story: At the outset of therapy, the client will be asked to outline the key problems that triggered them to seek therapy and the major incidents that have occurred in their life to date.
Write a reformulation letter: Once the therapist has obtained an overview of the client's difficulties and goals, they will write a reformulation letter outlining this information. This is then shared with the client and used as a basis for future sessions. They will also map out the client's problems on a piece of paper, so that both parties can refer to it as necessary. Set homework: CAT practitioners often ask their clients to complete homework between sessions. This may include thought records and exercises that encourage them to take a new approach to their problems.
For example
A client might be asked to draw or paint a particular feeling, or to create a portrait that communicates how they see themselves. The finished pieces can be a good way to start a conversation about the client's thoughts and feelings.
Fact
UK-based CAT practitioners usually have a minimum of two years post-graduate training alongside core training as a mental health professional (for example, as a psychologist or social worker).
Source: www.acat.me.uk
Module Summary
The basic ideas behind CBT can be applied as many different types of therapy. These include Acceptance and Commitment Therapy (ACT), Behavioural Therapy (BT) and Cognitive Analytic Therapy (CAT). ACT recognises that an individual's feelings are determined by how they interpret a situation, but it believes that all feelings should be accepted rather than reasoned away or resisted. The emphasis is on helping clients lead a meaningful life (whatever that looks like for them), rather than overcomingso-called symptoms of mental illness.
BT is a highly practical, typically straightforward form of therapy that draws on the principles of operant and classical conditioning to trigger behavioural change. For instance, rewards and punishments may be used to encourage or dissuade a client from engaging in an undesirable behaviour.
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