Friday 24 June 2011

What is CBT?

This is a question that often crops up - from students, from clients, from interested outsiders, from people interviewing me for jobs - and I want to give an answer that's both comprehensive and easy. It's up to you to decide how far I succeed!

What you see a lot of, these days, is people using the term 'CBT' as though it were the name of a specific therapy, and often confusing it with Beck's CT. I attended a talk, at the 2006 BABCP Conference in Warwick, in which the speakers described their research into childhood OCD. They said they'd compared CBT with Exposure and Response Prevention. Now that's pretty weird, given that Exposure and Response Prevention
 is a CBT. But what they meant (it transpired) was that they were comparing Beck's CT with Exposure and Response Prevention. These were well-qualified therapists, doing cutting-edge research, and yet they had been sucked into this terminological confusion.

It's pretty much the definition of what a therapy is (any therapy - including EST, Reichian Therapy, Analytical Psychotherapy, yada yada) that it seeks to replace an unwanted
 response with a preferred response. Like, if every time I see a worm I shriek and feel nauseous, the purpose of therapy is to change that reaction in some way, such that when I see a worm I stay calm. So what distinguishes CBT from other therapy models?

CBT, I argue, isn't a therapy; it's the umbrella term for a host of therapeutic methods. It includes Stress Inoculation, REBT, Exposure Therapy, Attribution Training, Self-Control methods, Beck's CT, and lots, lots more. On the whole we can categorise the CBTs into CTs and BTs, though any given implementation is likely to have fuzzier edges than that might suggest. For instance: are behavioural experiments a BT or a CT? I'd come down on the side of them being a CT, as they are meant to be persuasive. But opinions differ.

For me, the single concept that unites all of these CB Therapies is
 retraining. What we are doing is identifying unhelpful habitual responses, and teaching our clients how to retrain themselves out of those responses. In doing this they may exploit (under our guidance) a variety of psychological effects such as dissonance, habituation, overlearning, reciprocal inhibition, response competition and so on. So, exposure therapy retrains a certain visceral reaction, what we call arousal, exploiting the effect we call habituation. Or, practice of disputing irrational beliefs means practising a helpful cognitive habit (and, in Vivid REBT, forging an associative link between the unwanted emotion and the rational self-talk), which is a response that's incompatible with the original, harmful, response; so we're exploiting response competition and overlearning.

This is very different from behaviour modification. In BM the therapist is trying to modify the client's behavioural responses by manipulating the contingencies of their behaviour. For instance: if a child gets a hug every time it interrupts its parent, that's a contingency (if
 interrupts, then hugged). This is likely to result in a high level of parent-interrupting by the child. BM would look to change that contingency (to - perhaps - if interrupts, then ignored). Behavioural psychotherapy, on the other hand, involves instructing the client how to change their behaviour in order to alter their habitual responses, whether they be behavioural, cognitive or physiological.

3 comments:

  1. Cool. Welcome to the blogosphere! Their loss is our gain ;)

    Yes, the terminology is confusing, and different people use it in different ways depending on their point of view. But that unwanted/preferred replacement can't possibly be the definition of a therapy because it would include sports coaching, maths tuition and uncle Tom Cobley. There must be something more to it than that.

    The patient who shrieks and feels nauseous on seeing a worm is not typical of those I've encountered. More commonly the patient shrieks and feels nauseous for no apparent reason, or he is sure the reason is one thing when it's really another thing. Making the real reason apparent is the cognitive bit, to my way of thinking. Few patients hand their therapists the worm on a plate, as it were. Beck's CT is the basis of a methodology for finding it.

    In your last sentence you drop the word "cognitive" and I agree with you. What you have described here is only the behavioural part.

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  2. Interesting comment, "cbtish". You won't be surprised to hear that I don't agree with you:-) When I say "Behavioural Psychotherapy", I don't mean anything different from "CBT" - and, by "CBT" I don't mean "Beck's Cognitive Therapy", I mean all the behavioural and cognitive methods.

    Now, to your points:

    - In what way do you think that therapy isn't like (say) tennis coaching?

    - Fair enough, the worm analogy is a (deliberate) caricature. But you've said - if I interpret you correctly - that there's a skill in finding out what the real trigger is, and I completely agree with that. Still, when you do find what that reason is, what you then have is a S-R connection, a habit; and the therapist's job is to coach the client in how to retrain that habit.

    - I'd certainly agree that Beck's CT is a methodology, but I wouldn't say that it's the methodology. Hmm. I feel a post about CT vs BT coming on...

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  3. Ive always had difficulty with the idea of defining a therapy by techniques used, which are at best transitory. Ive wondered if it might be easier to think of all therapies reflecting a model of mind in practice. I think all therapies are essentially about learning, (why do you say retraining?) and this often involves work on insight but the different techniques used are based on beliefs about "how people work". When you talk about Beck I think you mean methods - What I'm saying is more reflective of a methodology.

    Looking at it in this way means you have to take into account systems like therapeutic communities, psychoeducation sessions etc.
    Are you saying BM is not a CBT?

    I know this this isnt very clear or easy but in reality techniques develop and improve based on improvements in the model. I know the current fashion in research is to focus on the pragmatic skills base, but if you can't make sense out of what you do its a good indicator of problems. Is EMDR a CBT or good old fashioned mesmerism.

    I hope this makes sense, I probably need to think this out more, it feels confused.

    I don't know, you start with what should be a nice simple post ...... :)

    Best wishes

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