Innovations in Cognitive Behavioral Therapy

Strategic Interventions for Creative Practice

Amy Wenzel

• Publisher: Routledge
• Year: 2017
• ISBN:
  9781317674146
• Edition: 1
• Topic: Psychology
• Subtopic: Psychotherapy
• Index: Psychology

Innovations in Cognitive Behavioral Therapy provides clinicians with a powerful arsenal of contemporary, creative, and innovative strategic interventions for use in cognitive behavioral therapy (CBT). This book goes well beyond standard CBT texts by highlighting new developments in the field and advancing a new definition of CBT that reflects the field's evolution. Throughout these pages, clinicians will find empirical research to back up recommended strategies and discussion of ways to translate this research into their clinical practice. Readers can also turn to the book's website for valuable handouts, worksheets, and other downloadable tools.

Chapter 1
Evolution of Cognitive Behavioral Therapy

Cognitive behavioral therapy, or CBT for short, is an active, semi-structured, time-sensitive approach to psychotherapy that aims to alleviate mental health and adjustment problems by addressing problematic cognitive and behavioral patterns that cause life interference and/or excessive emotional distress. By active, it is meant that the client and therapist both come prepared for the session, contribute to discussion, and work collaboratively together to address the client’s life problems. By semi-structured, it is meant that the therapist typically brings some sort of flexible but organized scheme to each session, as well as to the course of treatment, in order to ensure that therapeutic work is targeted and efficient. By time-sensitive, it is meant that clients enter treatment with the anticipation that treatment will eventually end, that the work done in each and every session is meant to advance treatment and to make a difference in their lives in between sessions, and that they will have the ability to implement therapeutic tools on their own, without the need to have a therapist coaching them in doing so.

What does it mean to address problematic cognitive and behavioral patterns? From a cognitive perspective, therapists help clients to recognize aspects of their thinking that are unhelpful and that could be exacerbating their emotional distress. This thinking could be thoughts or images that run through clients’ minds in particular situations, ways in which they interpret events in their lives, expectations that they hold for themselves or others, or underlying beliefs that developed from key developmental experiences. Intervention at the cognitive level can mean many things, from helping clients to modify their cognitions, to helping them to distance themselves from their cognitions and to live their lives the way they value in spite of their cognitions, or to coaching them to do something skillful to address their life problems so that a change in cognition will follow. From a behavioral perspective, therapists help clients to overcome avoidance, engage in healthy self-care habits, respond skillfully in the face of challenges and adversity, and participate in activities that they find meaningful and that give them a sense of positive reinforcement.

Many CBT strategies include both cognitive and behavioral components. For example, to implement effective problem solving, clients must have a centered cognitive orientation from which they approach problems, and they must enact effective behaviors in order to obtain a solution to their problems. As will be seen throughout the remainder of this volume, it is overly simplistic to limit cognitive behavioral interventions to only those that intervene at the level of cognition and behavior, as they are often targeted simultaneously as the session unfolds. Moreover, cognitive behavioral therapists are increasingly working at the level of emotion (e.g., Hofmann, 2016; Thoma & McKay, 2015) as well as at the level of large-scale environmental forces, such as discrimination (e.g., Hays, 2008).

The term cognitive behavioral therapy often evokes a noticeable reaction in mental health professionals. Some clinicians, like myself, are passionate about it, believing that it is a therapeutic approach that brings rapid and sustained relief from emotional distress and that it arms people with tangible strategies for preventing future relapse and recurrence. Other clinicians roll their eyes, indicating that claims about the efficacy of CBT are overstated, that the cognitive behavioral approach is too simplistic and does not get at the “real” underlying issues, or that CBT is “old hat” and that the field has moved on. Of course, as the purpose of this book is on innovations in CBT, I hope to disabuse the reader of these notions.

Whatever a clinician’s reaction toward CBT may be, the fact is that CBT is currently a central, if not the dominant, psychotherapeutic approach in both the contemporary psychotherapy research literature and in clinical practice. It is the psychotherapeutic approach that has the most extensive empirical base, demonstrating that it is associated with positive outcome relative to receiving no treatment at all and relative to receiving placebo conditions, such as minimal contact with a mental health professional (Butler, Chapman, Forman, & Beck, 2006). Results from survey studies indicate that more clinicians identify themselves with a cognitive behavioral orientation than with any other therapeutic orientation (Jaimes, Larose-Hébert, & Moreau, 2015; Norcross & Karpiak, 2012; Thoma & Cecero, 2009) and that rates of identification with the cognitive behavioral orientation have increased over time, whereas rates of identification with other theoretical orientations have decreased over time (Norcross & Karpiak, 2012; Norcross & Rogan, 2013). It is the psychotherapy that is taught most often to graduate students in psychology doctoral training (Heatherington et al., 2013). It is increasingly being viewed as the treatment of choice for many mental health disorders by insurance companies because of its time-sensitive (and thereby cost-saving) nature. There are also massive efforts to disseminate CBT to large treatment agencies, such as Veterans Affairs Medical Centers (Karlin, Ruzek et al., 2010; Karlin, Brown et al., 2012; Wenzel, Brown, & Karlin, 2011) and community mental health agencies in large urban areas (e.g., Stirman, Buchhofer, McLaulin, Evans, & Beck, 2009). Thus, there is no question that CBT has a firmly established place in the fields of clinical psychology, psychiatry, and other mental health-related disciplines.

This being said, the beauty of science and practice is that they evolve, and an approach that is stagnant runs the risk of becoming obsolete. Clinicians who practice from any theoretical orientation must have updated knowledge of relevant scientific findings, and they must translate that knowledge into their clinical practice. They must be in tune with societal trends that have the potential to affect the clinical presentations of their clients. They must have interaction with other professionals to obtain fresh perspectives on the way in which they approach complex cases. They must be open to consideration and evaluation of therapeutic approaches outside the mainstream of their typical practice.

Fortunately, cognitive behavioral therapists value these very points. Cognitive behavioral therapists consider themselves scientist-practitioners (or practitioner-scientists). This means that they truly value science, as evidenced by the fact that they keep up with the scientific literature and practice in a way that is consistent with what the literature says is efficacious. This also means that they use a scientific approach in their clinical work with clients, such that they find quantitative and observable ways to measure progress and to determine whether adjustments need to be made. In addition, cognitive behavioral therapists view environmental factors as important when they develop conceptualizations of clients’ clinical presentations. For example, the well-known cognitive behavioral therapist Robert Leahy has written extensively about applying cognitive behavioral principles to cope with and thrive during unemployment in response to the economic woes experienced by many during the most recent recession (Leahy, 2014). Moreover, cognitive behavioral therapists place great value on consultation with other professionals, at times viewing it as an essential part of the treatment package for clients with chronic mental health problems or for those who are at risk for suicidal and self-harm behavior (Linehan, 1993a; Wenzel, Brown, & Beck, 2009). Finally, cognitive behavioral therapists integrate techniques from other therapeutic approaches into their practice. A terrific example of this is the cognitive behavioral schema therapy approach, spearheaded by Jeffrey Young and his colleagues (Young, Klosko, & Weishaar, 2003), who have integrated many Gestalt, psychodynamic, and social constructivist interventions into their treatment. More about schema therapy is found in Chapter 5.

The purpose of this book is to highlight innovations in the science and practice of CBT, painting a picture of the flexible and contemporary study and practice of CBT. As is likely evident from its name, this book will not simply be another description of traditional cognitive behavioral strategies and techniques that are outlined in countless other CBT texts. Instead, this book briefly describes these traditional strategies and techniques in order to set the stage for consideration of the innovations that have stemmed from those traditional strategies and techniques, as one can only appreciate innovations if they understand the traditional approaches from which they developed. However, much of the focus of the volume is on new treatment packages, strategies, and techniques that have been evaluated in the research literature as well as ideas of the application and adaptation of standard and innovative techniques that have been tested in clinical practice but that must be verified by empirical research. It is hoped that after reading this volume, the reader will be able to answer the questions: Where has CBT been, where is it now, and where is it going? Although a detailed how-to description of each individual technique is beyond the scope of this volume, the ensuing discussion will provide a framework for understanding the ways in which these techniques are implemented, evaluating their effectiveness, obtaining more detailed information when needed, and thinking broadly and creatively about cognitive behavioral change.

The remainder of this introductory chapter is devoted to a consideration of the historical context in which CBT developed. It describes the predominant climate that characterized the fields of psychology and psychiatry at the time of CBT’s inception, and it highlights the independent contributions made by many giants in CBT’s history. It describes the expansion of CBT from a treatment for depression and anxiety to a treatment for a vast array of mental health disorders and adjustment problems as well as to its delivery in varied formats, settings, and populations. This chapter concludes with a glimpse of the traditional and innovative strategies that will be discussed in the remainder of this volume.

Origins of CBT

Many forces converged to form the “perfect storm” that provided the impetus for the development of CBT. In 1952, Hans Eysenck published a now classic paper criticizing one prevailing model of psychotherapy—psychodynamic psychotherapy—and proposing behavior therapy as an alternative. Eysenck provocatively raised the notions that neurosis need not stem from a deep-seated psychological conflict and that it can be treated in full by intervening directly at the level of symptoms (Eysenck, 1960; Rachman, 1997). The late 1950s and 1960s, then, witnessed increased attention on behavioral approaches to treatment that relied on principles of behavior modification, with British researchers primarily focusing on classical conditioning-based approaches to target fear reduction, and American researchers primarily focusing on operant conditioning-based techniques to target severe psychopathology in institutionalized patients (Rachman, 1997, 2015; Thoma, Pilecki, & McKay, 2015). However, as time progressed, it became evident that a strictly behavioral conceptualization was insufficient to account for the full range of clinical presentations that therapists see in their practices and that strictly behavioral interventions often left major components of problems unaddressed (e.g., obsessions; K. S. Dobson & Dozois, 2010; Rachman, 1997, 2015). According to Rachman (2015), “the dependence on conditioning processes… gradually ran out of steam” (p. 4).

Also happening at this time was that the field of psychology was going through a “cognitive revolution,” such that information processing models were being advanced (e.g., Neisser, 1967), and high-quality research was designed to measure many aspects of cognition, such as learning and memory. This is not to say that innovators developed cognitive behavioral approaches specifically to apply advances in cognitive psychology in clinical practice; in fact, a direct tie between the cognitive revolution and the incorporation of a focus on cognition into therapeutic intervention is often overstated (Rachman, 2015; Teasdale, 1993). Nevertheless, the field’s fresh focus on cognition created a climate that was ripe for the inclusion of cognition into traditional behavioral interventions. By the mid-1970s, scholar-practitioners were beginning to propose a mediational model, advancing the notions that cognition affects emotion and behavior and that intervening at the cognitive level would affect behavior change (e.g., Mahoney, 1974). According to Rachman (1997), “cognitive therapy [supplied] content to behaviour therapy,” and “cognitive concepts have widened the explanatory range of behaviour therapy and helped to fill in the picture” (p. 18). In the next sections, early cognitive behavioral treatment approaches are described.

Albert Ellis’s Rational Emotive Behavior Therapy

Beginning in the late 1940s and 1950s, Albert Ellis developed rational emotive behavior therapy (REBT, formally called rational therapy and then rational-emotive therapy) after questioning basic premises of the psychoanalytic model in which he was trained, observing that clients could develop sophisticated insight into their psychological problems but yet were still struggling (Ellis, 1962). The basic premise of REBT is that irrational cognition plays a large role in explaining people’s emotional and behavioral responses. Ellis developed the well-known ABC model, such that (A) inferences that people make about activating events stimulate an (B) irrational belief system, which leads to (C) consequences, which can be emotional (e.g., shame), behavioral (e.g., withdrawal), or cognitive (e.g., hopelessness) in nature (Dryden, 2012). The aim of REBT is to challenge (B) a person’s irrational belief system, characterized by rigidity and extremity, and shape it into a flexible and non-extreme belief system indicative of psychological health (Dryden, 2011). Ellis assumed that a person would experience decreased emotional distress and behave in a more adaptive manner if he or she substituted irrational beliefs with more realistic beliefs. The primary process through which this change occurred was through disputation, including questioning, challenging, and debating (Ellis, 1979). During the course of this process, Ellis actively encouraged clients to address directly the (largely self-imposed) obstacles that were keeping them from meeting their goals (Backz, 2011).

Ellis was a colorful personality and prolific writer whose clinical acumen exerted tremendous influence in the field. At a time when the prevailing model of psychotherapy was one in which the therapist was nondirective and even passive, Ellis blazed new trails by developing active, direct interventions and by asking his clients to complete homework in between sessions (DiGiuseppe, 2011). At times, he was provocative and confrontational—characteristics that very well might have turned some clinicians away from embracing this approach—but, nevertheless, it was an approach that his clients came to appreciate due to the hard work he exerted on their behalf and the timely progress they made (Backz, 2011; DiGiuseppe, 2011). Importantly, Ellis assembled a conference at his institute of like-minded clinicians (many of whom are described in this section) who believed in the central importance of cognition in understanding and treating mental health problems. As a result, he played a large role in solidifying a movement that provided a viable alternative to the more dominant psychodynamic and humanistic approaches that pervaded the practice of psychotherapy at the time (DiGiuseppe, 2011). However, Ellis was first and foremost a clinician, and although he encouraged outcome research, he did not pursue it with the same vigor as some of the other innovators described in this section. Thus, though REBT was perhaps the first CBT approach that was described in print, it plays a smaller role in the evolution of modern CBT than Aaron T. Beck’s cognitive therapy, described next (Backz, 2011; DiGiuseppe, 2011).

Aaron T. Beck’s Cognitive Therapy

Like Albert Ellis, Aaron T. Beck was trained in psychoanalysis and became disillusioned by it, observing that there was little empirical evidence for key unobservable psychoanalytic constructs and that a more parsimonious way to understand clients’ emotional distress was to examine the role of the meaning they were making from their life circumstances (A. T. Beck, 2006). He developed a cognitive theory in which he mapped particular cognitive distortions onto various emotional disorders (A. T. Beck, 1976) and published a seminal treatment manual on cognitive therapy for depression (A. T. Beck, Rush, Shaw, & Emery, 1979). The term cognitive therapy suggests that A. T. Beck gave central importance to the role of cognition in understanding emotional and behavioral problems. In fact, he later stated that “cognitive therapy is best viewed as the application of the cognitive model of a particular disorder with the use of a variety of techniques designed to modify the dysfunctional beliefs and faulty information processing characteristic of each disorder” (A. T. Beck, 1993, p. 194). Nevertheless, the treatment included a broad array of strategies, many of which were behavioral in nature, in order to create cognitive change and enhance emotional well-being.

Unlike REBT, cognitive therapy was subjected to rigorous empirical research to establish its efficacy. As is described in the subsequent section on the evolution of CBT, A. T. Beck expanded the empirical investigation of cognitive therapy from the treatment of depression to a host of other mental health conditions. Moreover, he also pursued rigorous examination of the tenets of his cognitive theory, simultaneously advancing cognitive theories of various manifestations of psycho-pathology. At the time of the writing of this volume, A. T. Beck is one of the most highly cited scholars in psychiatry and psychology.

Other Early Cognitive Behavioral Approaches

The 1970s was clearly an exciting time for scholars who were moving beyond psychodynamic, humanistic, and strictly behavioral approaches to the treatment of mental health disorders. At the same time that Ellis and A. T. Beck were molding their cognitive approaches, other innovators were assembling treatment packages that focused on the modification of problem behavior and cognition. Though these cognitive behavioral approaches did not have as pervasive an influence on the field or were applied to as many clinical conditions, they nonetheless deserve mention for their place in the history of this dynamic field. For example, early in his career, Donald Meichenbaum discovered that teaching people with schizophrenia to engage in “healthy talk” was associated with significant improvements in adaptive behavior, such as less distractibility and better task performance (Meichenbaum, 1969). He reasoned that when a person internalizes verbal commands, he or she is better able to exert self-control over his or her behavior. Thus, Meichenbaum concluded that covert behaviors, like cognition, could be modified usin...

Table of contents

• Cover
• Title
• Copyright
• Contents
• List of Figures
• List of Exhibits
• Preface
• Acknowledgments
• 1 Evolution of Cognitive Behavioral Therapy
• 2 Case Conceptualization
• 3 Motivational Interviewing
• 4 Cognitive Restructuring of Automatic Thoughts
• 5 Cognitive Restructuring of Beliefs
• 6 Behavioral Activation
• 7 Exposure
• 8 Affect Management
• 9 Acceptance and Mindfulness
• 10 Cognitive Behavioral Therapy: A Redux
• References
• Index