Introduction to Cognitive Behavioural Therapy Samenvatting
Les 1 11/11/2024
Cognitive Behavioral Therapy (CBT). CBT is a popular form of treatment nowadays. It is based on
theoretical models of learning and information processing. CBT is empirically supported. There is a
lot of empirical support for the models underlying CBT and the intervention itself and how effective it
is. CBT uses standardized protocols (gestandaardiseerde richtlijnen die worden gebruikt om
behandelingen systematisch uit te voeren. Voor iedere stoornis zijn specifieke stappen die
therapeuten volgen. De protocollen beschrijven bijv. welke interventies worden toegepast, de opzet
van een behandeling en hoe vooruitgang/effectiviteit gemeten worden. Het gebruik hiervan houdt de
therapie consistent en effectief is en vergemakkelijkt onderzoek naar de werkzaamheid van CBT).
The history of CBT (in short). The start of CBT is hard to pinpoint as it didn’t start as CBT.
- Late 1950’s/start of 1960’s (1 st gen) Behaviour Therapy (BT) originated. This work is based
on learning models which are theoretical concepts and principles that explain how behavior
is learned and changed. In the context of first-generation behavior therapy, learning models
were mainly influenced by the principles of:
o Classical conditioning (Pavlov) describes how neutral stimuli can be associated
with automatic responses.
o Operant conditioning (Thorndike & Skinner) describes how behavior is learned
through rewards and punishments.
These learning models are essential for development of BT, which focuses on the
relationship between a situation and the behavior that follows. It focuses on observable
behavior and changing this. A well-known concept in BT is exposure therapy, which is still
used today.
- Early 1970’s – 1980’s (2nd gen) Cognitive therapy (CT) (Beck). This theory is about
information processing. It is not the situation that leads to a behavior, but it is the processing
of the information in that situation that causes the behavior. So, a situation leads to
cognitions, which lead to behavior. E.g., you hear a certain noise downstairs at night and
when you think there is an intruder in your home you might get a baseball bat. However,
when you hear the same noise, but your cognitions are different, e.g., you think it is the cat
of the neighbors, your behavior and emotional/physical responses will probably be very
different. So, according to this, it is not the objective situation that produces behavior, it is
the appreciation and thoughts about the situation. So, the processing of the information
within a situation leads to a certain behavioral response. Cognitive therapy is concerned
with negative automatic thoughts. It is also about becoming aware of these negative
automatic thoughts and consequently change them (by cognitive restructuring). In this
therapy, you learn to identify these thoughts and change them. You can do this with the
Socratic dialogue (involves asking guided questions to help clients reflect on the validity of
their beliefs and assumptions).
- These two were integrated during 80’s into Cognitive- behavioral therapy (CBT).
- It has developed ever since into newer forms of CBT 2000’s onward (3rd gen) into
o Mindfulness Based Cognitive Therapy
o Acceptance and Commitment Therapy
o Dialectical Behavior therapy
New generation therapies focus on: emotions, languages, values and interpersonal relationships; but
the underpinning is still very much CBT.
,Status of CBT. CBT is the treatment of choice for many disorders. It is an important treatment option
for many disorders (anxiety, depression, psychosis, somatoform disorders, relation problems, work
related problems, child disruptive disorders, skills training in autism, etc.). It is an attractive choice of
treatment because it is often short term, complaint driven, and it has measurable effects.
Effectiveness of CBT. The effectiveness of CBT does depend on the disorder.
- They found strong evidence for the efficacy of CBT in anxiety disorders
o Social anxiety disorder & panic disorder (medium effects)
o Somatoform disorders (illness anxiety and BDD; medium to large effects)
- PTSD (medium effects) & OSD (large effects)
- Schizophrenia and other psychotic disorders positive symptoms
- Bulimia Nervosa, Insomnia & Personality Disorders CBT is found to be more effective than
other therapies
- Depressive disorder (major/persistent) mixed results, as effective as ADM
- Bipolar disorder not effective as a standalone intervention
- Substance use disorders effective for cannabis and nicotine, not for opioids and alcohol
Negative attitudes towards manuals. Generally, there is a negative attitude towards manuals and
protocolized treatments such as CBT. This might be because they disagree with the protocol, or
because they are unfamiliar with the protocol. Another cause for these negative attitudes is that CBT
is very labour intensive. Also, many psychologists argue that clients are often unique (comorbidity)
and they don’t think that the protocol will work for such specific clients. Sometimes, psychologists
are very confident in their own clinical judgements, and they prefer to rely on their own expertise
rather than standardized methods. Lastly, there is an overemphasis on general factors. This is based
on the Dodo-bird verdict (1980): “everybody has won, and all must have prices”. This refers to the
claim that all psychotherapeutic techniques are equally effective in the end. So, regardless of their
specific components, all empirically validated psychotherapies produce equivalent outcomes.
However, this is not true, new evidence says that some therapies are better than others.
Glenn Waller therapist drift. This describes the phenomenon where therapists deviate from
evidence-based treatment protocols, such as those used in CBT. Despite the proven effectiveness of
the protocols, therapists may often rely on their own intuition, make adjustments based on their
preferences, or prioritize relationship-building over the specific techniques recommended in the
treatment manual.
CBT is not perfect. Research shows that, depending on the type of disorder, 50-60% of people who
start treatment, reach recovery. However, there is a big difference between research and the real
world. In the research setting, there is a lot of control. This control/standardization is not present in
the real world. We refer to this as the efficacy (ideal situation) and effectiveness (real situation). If
therapists drift away from giving the treatment in the way that it is intended, the effectiveness of
treatment is reduced.
Therapists’ beliefs and attitudes. Some research findings:
- We rarely use treatment manuals and generally dislike them
o Despite better treatment outcomes
o Many clinicians have no idea what a manual is (50%)
- Psychologists overestimate the importance of therapeutic alliance
o How much of the treatment outcome is associated with alliance?
, Clinicians: estimate that it would count for 32% of the treatment outcome
Evidence: 4-5%
So, there is a big overestimation of how important therapeutic alliance is.
This influences how the treatment is given, etc. and it can cause a drift away
from the manuals.
- Does therapeutic alliance drive treatment outcome?
o Not in CBT
o Early behavioural change is a better predictor of treatment outcome
Why does this matter? CBT is not perfect, but when therapists drift from protocols, we
underperform on what it could deliver to clients. That would mean that people could suffer.
So, we can increase the effectiveness of treatment only by giving the treatment as it is
intended and adhering to protocols. So, we should start with reducing the red zone.
They studied the factors that are the best indicators for therapist drift. It seems that the
best indicator is experience. A study by Shapiro & Shapiro (1982) told us something very
scary: newer psychologists have better treatment outcomes than those with years of
experience. One of the main reasons for this is that new psychologists stick to the
treatment as it is intended and drift away less.
Practice of CBT
Characteristics of CBT:
- CBT focusses on the present, in contrast to many other forms of therapy
- The central question in CBT: why does the problem persist? And how can we change it? So, it
is not so much interested in the development of the problem, but in the maintenance of the
problem. It assumes that these two differ from each other. Also: how can we change the
maintaining circumstances?
- It is a problem-solving approach
- It is goal oriented, it is a very transparent form of therapy where you set the goals together
with the client
- It is very time-limited, you treat as long as necessary but as short as possible
- It focuses on thoughts, behaviors and emotions
In CBT, the focus is mainly on the behavioural or cognitive change, changing feelings is not
that easy and often a consequence of the change in someone’s thoughts or behavior. All
these relationships are bidirectional.
Structure of CBT
1. Validation of clients’ complaints
2. Building therapeutic relationship/engagement
3. Explaining general treatment rationale
4. Cognitive and behavioural assessment
5. Formulating realistic goals
6. Designing treatment plan
7. Carrying out treatment plan
8. Broadening to other areas of dysfunctioning
9. Relapse prevention
At the start of treatment, the client gets a lot of room to talk about the problems and the therapists
validates these and focuses on building a relationship. However, when the treatment progresses,
, there is less time for the patient to talk about the problems. Then the treatment starts. In CBT, you
continuously assess problem behaviour and cognitions.
Cognitive and behavioural assessment in CBT (very important)
- Aim to investigate the exact nature of the clients’ thoughts and behaviours.
- Initial approach formal assessment using interview, self-monitoring (ask clients to record
behaviours and the contexts), observations, etc.
- Maintenance assess the nature and impact of cognitions and behaviours continuously
during treatment phase and also in interaction with the client.
The assessment never stops in CBT. They are continuously done through CBT and in communication
with the client to continuously find out if it is consistent with the patients’ feelings and experiences.
Behavioural therapy (BT). Definitions:
- Behavioural therapy applying experimentally verified learning principles. So, BT uses
established concepts from behavioural science to modify maladaptive behaviour.
- Learning acquiring knowledge about the connection between events (= expectations) can
result in a behavioural change.
- Behaviour a logical response to a meaningful situation. BT focuses on understanding and
changing these observable actions through learning principles.
So, BT is about applying experimentally verified learning principles. The women in the video had
linked touching something with the illness of someone else. In BT, you try to break this contingency.
You teach someone that touching the toilet doesn’t lead to the expected outcome.
Learning model: abnormal behavior is achieved by the same learning processes as normal behavior.
The ways of developing, maintaining and changing behaviour are the same.
Problematic behavior: is often a deficit or excess of something.
The determination if behaviour is problematic or abnormal, can be very subjective. Therefore, we can
compare it to a general norm, assess impairments, look at health-related risks, or if it is illegal. So,
whatever you compare the behaviour to can be very important.
Basic principles of BT. Behaviour is produced by the interaction of a
person with his/her environment and behaviour is maintained by its
consequences. In BT we differentiate between 3 different concepts:
1. Antecedents of behaviour – conditions or stimuli that set the occasion for behaviour to
occur. We differentiation between two types of antecedents:
o Discriminative stimuli (SD):
o Establishing operations (EO)
2. Behaviour – anything a person does (or not does).
3. Consequences – effect that behaviour produces
o Immediate
o Delayed
