Unit 5 July

Unit 5 Cognitive Behaviour Therapy

In this essay I have attempted to show a personal understanding of Beck's theory of cognitive behaviour therapy with reference to the course materials and suggested reading, and to discuss its application with regard to people diagnosed with a learning disability. In order to show an understanding of the benefits and the drawbacks of Beck’s theory of cognitive therapy and its use in the treatment of emotional disorders, I have kept a diary of incidents over the course of one week which I have presented in the form of a chart (fig 1). I have avoided discussion of sensitive personal issues and have concentrated on those incidents that may be explained using Beck’s theory.

Beck’s Cognitive Therapy Beck’s theory of cognitive behaviour therapy suggests that existing schools of thought such as neuropsychiatry, psychoanalysis and behaviouralism are all based on the idea that the patient has no control over his condition, or his emotional state,

“Despite the striking differences among these dominant schools, they share one basic assumption: The emotionally disturbed person is victimized by concealed forces over which he has no control”

(Beck 1976) The intention of Cognitive Behaviour Therapy is to focus on styles of thinking that affect the subject now, rather than other forms of taking therapy which tend to focus on past events. It combines cognitive techniques designed to modify negative thoughts and beliefs, and behaviour therapy, which focuses on your response to those thoughts. Styles of thinking can become habitual to the extent that we begin to anticipate how we will react given a particular situation or set of circumstances. Because these responses are self imposed, Beck avers that with proper guidance the individual may learn to recognise (through what he calls metacognition) that thinking need not be automatic, but can in fact be easily modified. This involves consideration of alternative responses, examination of evidence to support the automatic response and the contemplation of a ‘worst case scenario’. Cognitive therapy suggests that events in themselves are not to blame for negative thinking, but the emotional response or significance that we attach to those events. During a course of cognitive therapy the subject will be asked to focus on and analyse their own responses to current or recent events. They may be required to keep a diary of events and responses to situations that cause anxiety. Because of this need for personal commitment and involvement outside the therapy session, this type of treatment does

not work for everybody. Traditional psychotherapy involves talking about past events in a free and open way but does not require commitment from the subject in the same way. Similarly, subjects with complex mental health issues may not find this type of therapy successful. CBT tends to be focused on specific problems and the alleviation of those problems. It is highly structured and practical in its approach. Beck stresses that “Symptomatic change should not be mistaken for a fundamental change of attitude in the subject “ (Beck (1976). In other words, a specific symptom or problem may be alleviated through cognitive modification, but this will not have long term benefits if the underlying thought process is not modified.

"The underlying attitude, however, is the component that needs to be changed ultimately if the totality of the depression is to be influenced. Thus, the goal is cognitive modification." (p. 268) (Beck ibid.) When compared with other therapeutic techniques, there seems to be little to choose between CBT and others. A study undertaken in Germany in 2001 showed the effects of short term psychodynamic psychotherapy on patients suffering from depression compared with

cognitive behaviour therapy . In 97% of the comparisons it was regarded that: “STPP and CBT/BT did not differ significantly with regard to the patients that were judged as remitted or improved.” (Leichsenring 2001) More recently, this year a study of the comparative efficacy of behavioural couples therapy (BCT) carried out in Holland showed that, when applied to couples suffering from the effects of alcohol addiction, there was little to differentiate between the effects of treatment via BCT and CBT: “ Stand-alone BCT is as effective as CBT in terms of reduced drinking and to some extent more effective in terms of enhancing relationship satisfaction. However, BCT is a more costly intervention, given that treatment sessions lasted almost twice as long as individual CBT sessions.” (Vedel et al 2008) This seems to indicate that CBT is at least as effective as other approaches in the treatment of conditions such as depression and anxiety and in treating addictions.

The Cognitive Triad Beck refers to the circumstances that lead to depressive thinking as the "cognitive triad." (Beck, 1970) The cognitive triad can be used to explain how those who are depressed view themselves, their world, and their future. An event will trigger an emotional response in a given individual. This response will vary from person to person. a depressed person may feel that any event which affects him will have a negative consequence. Firstly, the depressed person thinks that there is something wrong with him or her that makes happiness impossible. For example, a depressed person thinks, "I am a loser" or "I am stupid." Secondly, because of this perceived personal inadequacy the depressed person notices negative circumstances but ignores positive, fortunate circumstances. Thirdly, because of the belief that he or she is inadequate, and his or her tendency to only notice negative experiences, the future is viewed as certain to be gloomy, dismal, and painful. For example, the depressed person may frequently receive positive feedback concerning his or her performance at work. A customer or colleague -- who is obviously in a bad mood -- complains. The depressed worker can only think about the complaint and sees it as

confirming what a poor worker he or she is. The many positive comments that have been made are not even remembered.

According to Beck and Emery (1985), "Anxious patients in the simplest terms believe that something bad is going to happen that they won’t be able to deal with."

It is the fear that leads to irrational and instinctive reactions, designed to avoid the expected conflict and protect the individual.

They advanced three basic strategic questions detailing how a process of cognitive restructuring could be achieved in this case. 1. What is the evidence supporting the conclusion currently held by the client? 2. What is another way of looking at the same situation but reaching another conclusion? 3. What will happen if, indeed, the current conclusion/opinion is correct?

Example C from the chart below describes a typical thought process of mine. I am awake early; my first thought is that I have woken because I am

worried about the essay I have yet to complete. It does not occur to me that I may have been woken by the cat or by a car starting outside. This assumption leads to the notion that I will not be able to be happy, or feel relaxed until this piece of work is complete. This notion then begins to affect my state of mind, to the point that when a colleague or friend asks me “how are you?” I immediately focus on the one thing that is causing me to feel negative and explain that I am not feeling good because of this unfinished task. Taking the example above, it could be said that I am feeling negative about myself, because I believe I am not sufficiently skilled to complete the task at hand; this makes me feel negative about the world, in that I cease to enjoy the process of learning and am an unfit student; and thus negative about the future, I am unlikely to get a pass mark, and will probably fail the course. The problem here is that some of these events will happen, not because I am being negative, but because they may actually reflect the situation as it is. I can begin to see this as part of a wider, more fundamental problem with my thinking. I dread the idea of failing and consequently I hate getting things wrong. It is clear that my reactions are automatic to a marked degree, and it is only when considering my reactions and behaviour at a distance that I am able to realize what I should have said and done.

Diary

I chose a week at random during which to record incidents where I felt mild negative reactions to specific events. As suggested I have recorded these incidents on a chart (Fig 1). Below I have tried to evaluate each incident in turn as it relates to the theory under discussion. Example A Situation I am attending a mandatory training session at work; all of the other students are younger support workers, and as such, junior to me in terms of age and experience. I am certainly the most experienced person in the group, and should be able to answer the majority of the questions. Next to me is a female staff member, who has joined the company only recently. She has little experience of this particular field, yet she consistently fields answers to the tutor's questions. I feel myself getting annoyed by what I see as her attention seeking behaviour. She refuses to use a chair and sits on the floor; she takes her shoes off; she is happy to blurt out answers despite her evident lack of knowledge. She behaves as if she knows people well, despite having never met them before. Later, when we break for lunch, I end up seated next to her, and feel my irritation increasing as she talks about herself. She also begins to discuss residents at the care home where she is working, people with whom I used to work. I know she is not observing confidentiality, and is using proper names and

discussing their behaviour. She is later reprimanded for this by our tutoy.

Evaluation I do realise that she is unreasonably irritating me, and this in itself begins to annoy me. I feel the urge to put her straight on a number of issues, but feel disinclined to confront her openly. Instead I make a few vague remarks, in a way that is as ineffectual as it is pointless. My criticisms are far too subtle to get through. In the context of this training session, we are all students and have an equal right and opportunity to contribute. This could be characterized as my jumping to conclusions about the individual concerned, although what seems more significant in this situation is my concern about my own position within the group. Why do people like this bother me so much? This personalisation leads to problems at times as others will not be judging the situation by the same criteria, and I will assume that others are thinking what I am thinking.

Example B Situation Thursday

I am on the phone to my credit card company, in answer to a letter I have received about non payment of bills. This is the third time I have addressed this issue and I begin the phone call in an already heightened state of anticipation. I have my explanation to hand, as well as the information I have gathered during my previous encounters. There has been an administrative error which, although being corrected over the phone has not yet been reflected as a payment.

The reason I am so tense is that my wife has already cast doubt upon my ability to handle finances, and sees this as just another mistake on my part. I am annoyed with her because I feel she has a valid point about my responsibility where domestic finances are concerned, although to be fair in this particular case I have met my responsibilities. It has been established from past experience that I am not very good at this. Because of this, I avoid dealing with money wherever possible. And yet here I am making a considerable meal of what should be a very simple phone call, because I do not only have to please the company and my bank, but also have to please my wife. Here is an example of over generalization, my assumption that call center staff are going to be unhelpful, officious and ill informed. I forget that I once worked in a box office and all day long had to field calls from

disgruntled cinemagoers. This knowledge has no effect on my attitude at the time. I am forgetting that call center personnel are provided with protocols they must follow in order to do their job efficiently, and in this case, protect the confidentiality of their customers. There is a certain element of personalization here as well, as I have done all I can to reach a satisfactory resolution of this issue, but continue to blame myself and accept blame from others for the continuing problem.

Example C Situation Friday morning I awake at 5.30. My alarm is due to go off in one hour. Hardly enough time to go back to sleep, even if I wasn't worrying about this very essay you are reading now. I should be putting aside time to read the course materials and then, having made some notes, start to put together my ideas. I haven't done a stroke. I have plenty of time. I believe I have the ability to write succinctly, but I am convinced I will not be able to make a good job of meeting the requirements of the task. So I avoid it, make excuses and do other things, then I remember what I should be doing and feel anxious. Faced with the reality of having to work and have that work judged, I consider how it would be if I just didn't do it. What's the worst that could happen?

In this situation I would feel as if I had failed, and believe that everyone else would feel the same. I would have to live with the knowledge that if I had only sacrificed some of my leisure time, and got down to work I could have succeeded. This could be described as a form of absolutism – if we assume that I want to complete the set task and make a good job of it, then assuming that I will fail must be based on previous experience. The evidence is that when I concentrate and apply myself then I am able to complete an essay successfully; when I do not then my work suffers. The worst that could happen is that I would be forced to recognize my own shortcomings, and for me this seems to be the worst thing of all.

Example D Situation Saturday night My wife and I throw a party for her birthday. I actually have very little involvement, as she invites everyone and makes arrangements. I have to work in the morning and so I begin to feel a little uncomfortable about going to bed, as I don’t think I will be able to sleep with all the noise. I recall similar situations in the past when I have become angry and upset by this kind of situation. Everybody is, however, extremely understanding and I am left in peace.

I can begin to see a pattern emerging, with which I confess I am quite uncomfortable. There is a common element of personalisation. I am only concerned about how this evening will affect me; I appear to have forgotten the fact that it is my wife’s birthday, and that the guests have been invited to enjoy themselves and our hospitality. I am unable to relax and participate and look to blame my discomfort on the behaviour of others. To make matters worse, the next day when this is pointed out to me I become angry and defensive; it seems I wish to reserve the right to be right, even when I know I am wrong.

Example E Situation My wife mentions the events of Saturday night and offers her opinion that I could have been more sociable. I feel aggrieved and become annoyed with her Again, personalizing the issue, I seem to require that others should see my point of view: I had to work the next day, I needed an early night etc. Realistically, the worst outcome would have been a sore head and feeling tired the next day. I have frequently chosen to go out and enjoy myself on weeknights and have suffered no ill effects the next day; the difference seems to be that I have chosen to do this, and I stand to benefit from it in some way, rather than having to put aside my

personal needs in order to benefit another. My wife is of course right about my motivation and it seems it is this feeling of transparency that I am so uncomfortable with. I want to feel that I can behave badly, and pretend that I am not. Thinking Styles A theme that runs through this exercise is my tendency to focus on how others’ behaviour affects me, and not how mine is likely to affect them. This self directed thinking is bound to create situations where the satisfaction of the needs of others becomes secondary to my own. The discovery that those around me do not share my immediate concerns seems to come as a shock, and this leads to negative thoughts about myself in any social situation. What would seem to help here would be to develop a response that focuses on putting the needs of others first as a matter of course, in the way I am required to do in my capacity as a carer. It is perhaps significant that the situations I have described, with the exception of the training session, have all taken place outside of work. My workplace is a highly structured environment with clear rules and procedures, and where my responsibilities are clearly circumscribed. There is a tendency to resort to “all or nothing” thinking at times which allows me to withdraw and accept failure as an option, rather than setting a realistic goal and setting out to achieve it. Sanders (1997) describes and expands upon Beck’s idea of cognitive distortions, which lead to an individual’s

thinking becoming thematic. “These themes become elaborated and maintained by the day-to-day ‘dripping tap’ effect of the client’s ‘negative automatic thoughts’” Hence an individual’s negative thoughts become automatic and serve to reinforce the underlying ‘theme’, in my case, what Beck terms crystal ball gazing, where I tend to predict a negative outcome despite evidence to the contrary.

Cognitive Behaviour Therapy for people with a learning disability Applying this kind of therapy to someone with a learning disability raises numerous issues involving consent, effective communication and confidentiality. Dagnan and Chadwick (1997) describe a model (suggested by Trower, Casey and Dryden 1988) that enables a person with a learning difficulty to engage in a simple form of cognitive therapy, using a framework of Antecedent, Belief and Consequence (ABC). In this model the subject is not required to make judgements or evaluations of events or the emotions stirred by those events. The event (A) is followed by a consequence (C) that is dependent upon the beliefs or inferences (B) held by the individual, rather than the antecedent itself. This simplified process does not delve as deeply as cognitive therapy but nonetheless involves the subject in a process of cognition, and regarding his reactions in direct relation to his own

beliefs. They quote Beck's demonstration that "inferences in the form of anticipations and recollections tend to be distorted and biased because of the influence of mood" Dagnan & Chadwick 1997 An assessment of 29 people enabled them to establish that at least some people with learning disabilities are able to distinguish between events, beliefs and the emotions that follow as a consequence, and that such people could benefit from this type of therapy. This suggests that an adapted form of cognitive therapy can be useful in dealing with depression and anxiety for those with a learning disability. Lindsay, Neilson and Lawrenson (1997) describe two cases in detail where cognitive therapy has been shown to be effective. One case involved a course of treatment over the period of a year, designed to alleviate the extreme anxiety displayed by the subject, who was unable to leave his flat due to his fear of being attacked, and who also became highly anxious when indoors. The resultant anxiety led him to set fire to his flat. He was found to be having several automatic thoughts which led him to misconstrue his situation and exaggerate his feelings of loneliness and fear. A process of daily assessment using histograms was used to work on these negative automatic thoughts. The therapy enabled him to replace these negative thoughts with

simple adaptive thoughts. Another subject was encouraged to keep a diary and to view slides which were used to monitor his reaction to panic attacks when having to work around women. In both cases the Beck Anxiety Inventory and Beck Depressive Inventory scores showed a marked improvement.

Problems The difficulties inherent in adapting cognitive interventions for people with learning disabilities are discussed by Jones et al(1997) They state that problems with language, poor memory and information processing can and have been overcome, but there remain problems with motivation, self esteem and social cognition. Motivation suffers as a result of dependency upon others which is often characteristic of individuals who have lived most of their lives in an institutionalised environment. This dependency leads to feelings of helplessness and an unwillingness to try (Zigler and Hodapp, quoted in Jones et al) and coupled with a desire to please others at the expense of themselves results in low self motivation. The failures produced by this lack of motivation contribute to feelings of low self esteem. Beck’s theory seems to play down the influence of environmental factors such as hormonal imbalance, illness, tiredness and boredom as well as the irrational and unreasonable behaviour of others. Certainly we can correct our negative thoughts in situations such as these, or at

least recognize that things will probably improve after a good night’s sleep, but these are not stimulated purely by our negative thinking, they are to a greater or lesser extent, beyond our control. Beck refers to “common sense” as a principle, and this certainly has value when we are evaluating our responses to events. Andrews (1996) shows that the effectiveness of cognitive therapy can be measured favourably against other psychological treatments, such as counseling and psychotherapy. The OED tells me that counselling is “help or advice given formally”, my own lay definition would be a process of communicating between two individuals, where one individual is charged with the responsibility of encouraging the other to talk openly about him or herself without fear of being judged or criticized. One person cannot tell another how to think or feel, nor do they have the right in a situation like this to give an opinion as to whether a particular thought or way of thinking is right or wrong. the British Association for Counselling is quite clear in it’s definition that, “It does not involve giving advice or directing a client to take a particular course of action” (BAC 1979) The relationship that develops between the counselor and the individual seeking treatment is a complex and influential factor in the

success of the intervention One of the major drawbacks of Beck’s theory is the assumption that there are right and wrong ways of thinking, and that this assumption may inform the relationship between the counsellor and the individual seeking advice.

Conclusion Beck suggests that negative thoughts can be seen as part of a cognitive triad; these thoughts can be about oneself, the world around us or our view of the future. These negative or erroneous thinking styles do not necessarily need an event or interaction in order to become effective; they can be stimulated by your own emotions, thoughts and recollections. The principle of cognitive behaviour therapy is an attractive one to the person seeking treatment. The suggestion that we as individuals can take control of our thought processes is an empowering idea. A counselor should be able to steer the individual towards a more balanced and rational thought process without suggesting that the subject is ‘wrong’ in his or her thinking, but merely the victim of a self imposed negative viewpoint. It is possible to apply this technique to persons with a limited use of language or poor information skills, such as may be found amongst those labelled as learning disabled. It demands an adapted form of questioning and careful screening firstly to identify those who may be suitable candidates, but those who meet

the criteria have been shown to be capable of modifying their cognitive processes and achieving some resolution.

References Andrews, G. (1996). Talk that works: The rise of cognitive behaviour therapy. British Medical Journal, 3(13), 1501 – 1502

British Association for Counselling. (1999). What is Counselling? Training and Careers in Counselling. Rugby, Warks: British Association for Counselling. (Extract)

Beck, A. (1970). Depression: Causes and Treatment. Philadelphia: University of Pennsylvania Press.

Beck, A. (1976). Cognitive Therapy and the Emotional Disorders. New York: International University Press

Beck, A.T., & Emery, G. (1985). Anxiety disorders and phobias: A cognitive perspective. New York: Basic Books

Dagnan, D. and Chadwick, P.(1997) Cognitive -behaviour therapy for people with learning disabilities: assessment and intervention. In B. S. Kroese, D. Dagnan and K. Loumidis (eds) Cognitive-Behaviour Therapy for People with Learning Disabilities. New York: Routledge.

Jones, Robert S.P., Miller, B, Williams, H, Goldthorp, J. (1997) Theoretical and practical issues in cognitive-behavioural approaches for people with learning disabilities: A radical behavioural perspective. In B. S. Kroese, D. Dagnan and K. Loumidis (eds) Cognitive-Behaviour Therapy for People with Learning Disabilities. New York: Routledge.

Leichsenring, F. (2001) Comparative effects of short term psychodynamic psychotherapy and cognitive-behavioral therapy in depression: A meta-analytic approach. Clinical Psychology Review Vol 21, issue 3, 401-419

Lindsay, W., Neilson, C. and Lawrenson, H.(1997) Cognitive behaviour therapy for anxiety in people with learning disabilities. In B. S. Kroese, D. Dagnan and K. Loumidis (eds) Cognitive-Behaviour Therapy for People with Learning Disabilities. New York: Routledge.

Sanders, W.F. (1997) Cognitive Therapy: transforming the image.

London. Sage.

Vedel, E., Emmelkamp, P.M.G., Schippers, G.M., (2008) Psychotherapy and Psychosomatics, Vol 77, No. 5

www.personalityresearch.org/papers/allen.