An Introduction to Cognitive Behaviour Therapy, 2 edition

17

Developments in CBT

Introduction

CBT was originally developed to help those suffering from clinical depression and has gradually been extended to a wide range of psychological disorders. By the 1990s, the model had been elaborated to include the cognitive, emotional and behavioural processes that might underpin the difficulties of clients who experience more complicated problems, including personality disorder.

The most clinically prominent models for complex clients emphasise the role of schemata (or schemas) in cognitive and behavioural difficulties, and these have given rise to approaches to cognitive therapy which are overtly schemafocused (Beck et al., 2004; Young, 1990) and those that indirectly address problem schemata (Gilbert, 2005; Linehan, 1993). These schemafocused developments will be given prominence in this chapter, as well as other important models and theories that have given rise to exciting possibilities for enhancing or shifting the emphasis of interventions. These include the interacting cognitive subsystem (ICS) model (Teasdale & Barnard, 1993), which underpins mindfulnessbased cognitive therapy (MBCT) (Segal, Williams & Teasdale, 2002); and relational frame theory (Hayes, BarnesHolmes & Roche, 2001), which provides the theoretical basis for acceptance and commitment therapy (ACT).

The past decade has also seen the emergence of behavioural activation (BA) (Jacobson, Martell & Dimidjian, 2001), a therapy that focuses on a single component of CBT for depression (see alsoChapter 12).

Each of these developments can only be briefly reviewed in this chapter; therefore, the reader is advised to refer to the available training manuals or publications for detailed guidance.

Why consider moving outside the framework of traditional CBT?

First, on an adhoc basis, traditional CBT might require modification or elaboration to be effective. This may mean extending treatment sessions beyond the number indicated by a treatment protocol or ‘adding’ an extra intervention to supplement the protocol when the client has, for example, to deal with an unforeseen life event.

Furthermore, CBT is not the optimum therapy for all psychological problems and is not accessible to all clients. In some instances, other forms of psychotherapy are more helpful, for example, family therapy in the treatment of AN (see Eisler, le Grange & Asen, 2003, for a review).

Second, some practitioners have elaborated cognitive therapy in a substantial way in order to increase its accessibility to and effectiveness for those with chronic and complicated problems. This includes the expansion of interest in interpersonal processes in cognitive therapy (Safran & Segal, 1990), the development of schemafocused cognitive therapy (SFCT) (Beck et al., 2004), schema therapy (Young et al., 2003) and MBCT (Segal et al., 2002), which combines CBT with mindfulness training.

Third, some practitioners have streamlined traditional CBT by focusing on specific aspects of it. For example, BA (Jacobson et al., 2001) deemphasises the cognitive components of traditional CBT in the treatment for depression.

A therapist might consider moving outside the traditional framework of CBT when the ‘classic’ approach seems to be insufficient yet the client seems suited to CBT and the formulation of the client’s problem appears to support a cognitivebehavioural intervention. In some instances, there are guidelines to indicate which clients might be helped in this way. For example, MBCT is advocated as a treatment for recurrent depressive disorder, compassionate mind training for those whose progress seems arrested by selfcriticism and shame, and SFCT for clients who are ‘stuck’ because of the resilience of longstanding negative belief systems. These approaches are discussed later in this chapter.

Schemata in therapy

What is a schema?

There is agreement that a schema is more than a belief: it is an informationprocessing structure that enables us to classify incoming information and to anticipate events. Some authors argue that it is a purely cognitive structure, while others argue that it is more complex and multimodal. We all have schemata, about ourselves, about categories of events and so on. These knowledge structures enable us to process, with speed, what is happening and help us render the environment predictable. It is accepted that, in general, schema develop from early childhood and subsequently predispose a person to interpret themselves, the world and the future in a particular way.

Williams, Watts, McCleod and Mathews (1997) give a succinct description of a schema as ‘a stored body of knowledge which interacts with the encoding, comprehension and/or retrieval of new information within its domain, by guiding attention, expectancies, interpretation and memory search …[a] consistent internal structure, used as a template to organise new information’ (p. 211). You might ask: ‘What does this mean in practice?’ Consider the following brief passage:

 

Mary walked down the aisle, the congregation was silent and her parents looked on proudly.

She readjusted her mortarboard slightly.

You probably quickly concluded that this was Mary’s graduation ceremony even though there is no mention of graduation. Your previous knowledge of ceremonies furnished you with the information that you needed to ‘read between the lines’ and to anticipate what was happening. This body of knowledge resides in a schema. Thus, schemata are highly functional – and flexible (there is a reasonable chance that you were holding out for a wedding until you read ‘mortarboard’ and switched to an alternative possibility). This ability to make a rapid deduction on the basis of limited information generally serves us well, but problems arise when the content of a schema is biased or is inflexible. When this happens, a person can ‘read between the lines’ inaccurately. For example:

Rosie’s boss had barely finished saying ‘You look well today!’ when she felt overwhelming distress and had to get out of the room. The thought running through her mind was ‘He thinks I look fat!’ and the feelings that she experienced were fear and self-loathing.

Rosie’s selfschema was so biased towards the negative that when her boss commented on her appearance, she ‘read between the lines’, and, instead of perceiving a compliment, she believed that she had been criticised.

Beck et al. (1979) recognised the position of schemata in the cognitive model of depression. He acknowledged that accessible thoughts (automatic thoughts) are coloured by ‘deeper’ mental structures (schemata). For example, a selfschema represented by the label ‘hopeless’ could well underpin NATs such as ‘There’s no point in trying’ or ‘Things will never go well for me’; an interpersonal schema, represented by ‘mistrust’, might explain NATS such as ‘He’s only saying that to manipulate me’, or ‘Others will leave me in the end’.

Although schemata have long been recognised as ‘enduring structures of knowledge’ (Neisser, 1976), they are flexible to varying degrees, enabling us to change our attitudes and expectations as we have new experiences. For example, with managerial experience, a person’s view of self might shift from ‘I can’t handle people’ to ‘I can manage others’; following a traumatic experience, a person’s view of the world might shift from ‘basically safe’ to ‘threatening and dangerous’. CBT exploits this by working in the ‘here and now’, offering clients new possibilities, encouraging new experiences which might have an impact at the schema level.

Schema-focused work

Some clients, however, present with schemata that seem resistant to change even in the face of new evidence. This is seen to be pivotal in the maintenance of chronic psychological problems, including those associated with personality disorders. Typically, clients with changeresistant schemata cannot embrace a positive experience that challenges a negative belief. Instead, they repeatedly dismiss it with comments such as, ‘Yes but he’s only saying that out of pity’, or ‘Yes but that was down to luck’. Some clients, such as Rosie, never get as far as appreciating the positive experience; they rapidly distort it to a negative event that sits comfortably with their inner, negative perspective.

This is the client group for whom schemafocused, or ‘second generation’, cognitive therapy (Perris, 2000) was developed. The resilience of unhelpful schemata demanded the development of strategies that could more directly target them and an approach that could facilitate this. Thus, schemafocused work is an elaboration of traditional CBT with a shift of emphasis – it is not a distinct, new approach.

The approach puts greater emphasis on understanding the childhood and adolescent origins of psychological problems and on the client–therapist relationship, placing the formulation in a greater historical and interpersonal context. As far back as 1979, Beck et al. suggested that ‘the use of childhood material is not crucial in treating the acute phase of depression or anxiety, but it is important in the chronic personality disorders’.

Practitioners have emphasised using the client–therapist interaction to more readily uncover sensitive or elusive core themes, to engage clients with interpersonal difficulties or profound hopelessness and to use the relationship as a mediator of change (Perris, 2000; Beck et al., 2004). In cognitive therapy, transference is not assumed to be operating but is a possibility to be explored. In their particular practice of Schema Therapy, Young et al. (2003) particularly emphasise the therapeutic value of ‘partial reparenting’ and ‘empathic confrontation’, both of which assume that the therapeutic relationship represents a medium for change.

Schema work is about developing new, helpful belief systems that will be to the client’s advantage and will compete with old perspectives – simply demolishing old beliefs can leave a client in something of a void. Many of these strategies are elaborations of ‘classic’ CBT techniques and include the following.

Positive data logs (Padesky, 1994) are systematically compiled lists of positive experiences that serve to build new, more constructive belief systems and that challenge old, less helpful perspectives.

For example, Rosie collected information that was consistent with a new possibility: ‘I am an attractive person’. First, she compiled a list of qualities which she found attractive in others:

 

  • A ready smile
  • Genuine warmth
  • Kindness
  • Tolerance
  • Fairness.

Rosie was interested that her list did not contain descriptions of physical appearance, and she reflected that others might share similar views. She used this list as a checklist and noted each time she became aware that she fulfilled one of her criteria, or when someone paid her a compliment indicating that she was attractive. At first, it was difficult to recognise the positives and she needed encouragement to continue to keep the log, but, with practice, Rosie became more adept at noticing compliments and achievements. In this way she both collected information to help her construct a new belief system and she developed the skill of noticing positive events.

This technique is not a fundamentally new strategy but more an elaboration of the datacollecting exercises that we use in traditional CBT. However, it is generally more effortful for your client and will span a longer period.

Continuum work or ‘scaling’ (Pretzer, 1990) is a strategy for helping clients combat an unhelpful dichotomous thinking style. In classic CBT, we often help clients recognise their ‘allornothing’ thinking and prompt them to take stock of the range of possibilities linking the extremes. Continuum work builds on this and involves drawing out the spectrum that lies between the extremes, discussing and weighing up the validity of an ‘allornothing’ perspective (this is also discussed in Chapter 8).

In Rosie’s case, she held a dichotomy of ‘ugly or attractive’ and, unless she was given a very unambiguous message that she was attractive, she perceived comments as confirming that she was ugly. In therapy, she began to realise a continuum of attractiveness existed and that it included more than physical appearance.

Historical logs (Young, 1984) are retrospective thought records. Key incidents from the past are reevaluated in a systematic way, reviewing the historical reasons why a belief might have seemed compelling and why its validity might now be doubted.

Rosie dated her belief that she was ugly to several incidents from her past, including an incident at age eight when a group of children surrounded her and chanted that she was ‘repulsive’. She reflected on why it was that she believed them at the time:

I was overweight and my parents never did anything but criticise me.

Now, however, she could use her ‘wise mind’ to challenge the conclusion she drew as an eight-year-old:

I was a regular-looking, slightly chubby girl who was scapegoated by a group of kids who knew no better.

She then drew a new conclusion:

I was vulnerable to believing criticism because of my home life, but I can now see that those kids were being superficial and cruel, which reflects badly on them rather than on me.

The responsibility pie technique (Greenberger & Padesky, 1995) encourages a client to consider who or what else might have contributed to a difficult situation. Sometimes our clients assume that they are predominantly, if not totally, responsible for bad things that have happened and they feel painfully ashamed:

In Rosie’s case, she blamed herself for being overweight, which fuelled self-loathing, shame and depressed mood. Her therapist prompted her to think who or what else might have contributed to her being overweight. At first she struggled, but slowly generated a list:

 

  1. The food industry, who package and advertise food to make it so appealing.
  2. My depression, which leads me to comfort eat.
  3. My parents, who were unsupportive so that I turned to comfort eating.
  4. My mother, who was always dieting but fed me the food she craved, which made me a fat child.
  5. The children who teased me for being ‘fat’, which triggered my obsession with weight.
  6. My dance school, which indoctrinated us with the idea that only thin is acceptable and contributed to my obsession with weight.
  7. My obsession with weight: I am preoccupied with food.
  8. My aunt, though I love her dearly, who tried to cheer me up with chocolate treats, which is probably why I find chocolate particularly tempting.

When she had exhausted all possibilities, she added her name to the bottom of the list. nd chocolate particularly tempting.

For some clients, this alone is sufficient to modify an extreme view of responsibility, as they now realise that there were many contributors to their problem. However, Greenberger and Padesky suggest taking the exercise further and asking clients to estimate how much each person/thing contributed and then to convert this to a pie chart. While this is too demanding for some clients, it can be helpful to others.

In Rosie’s case, her ratings were as follows:

1

The food industry

5%

2

My depression

10%

3

My parents

40%

4

My mother

10%

5

The children

10%

6

My dance school

5%

7

My weight obsession

15%

8

My aunt

1%

9

Myself

4%

When she reached the bottom of the list, Rosie discovered that she only had 4% left to apportion to herself, and, as a consequence, felt less shameful and angry with herself. Her pie charts are shown in Figure 17.1.

Figure 17.1    Rosie’s responsibility pie charts

If your client thinks that this is a trick and you have manipulated the figures, you can ask them to review their estimates and change the figures with which they are not happy. In general, your client will still end up with a responsibility figure for themselves that is less than they had originally expected.

It is important that you encourage your client not to conclude, ‘I am not responsible, therefore there is nothing I can do about it’. Although a person no longer feels responsible for something happening to them, they can take responsibility for moving on. You might not be responsible for your central heating breaking down, but you can take responsibility for getting it fixed.

Schemachange strategies have also involved the development of ‘experiential techniques’, reflecting the role plays and visualisations used in classic CBT but also drawing on Gestalt techniques and complex imagery exercises. For example, Rosie benefited from what Padesky calls psychodrama (Padesky, 1994), a role play of an interaction with her dead father which enabled her to confront him about his emotional and physical abuse. She was also helped by engaging in image restructuring (Layden et al., 1993), where she reviewed the image of being ridiculed by schoolchildren, reconsidered her responses and conclusion and then rescripted an ending with positive connotations.

For Rosie, this new image was of her walking away feeling tall and attractive (rather than cowed and ugly), confident in her knowledge that they were wrong and that she was morally superior. She particularly focused on the physical sensations of feeling tall and attractive, as this challenged her ‘felt sense’ of ugliness.

Such bodyimage transformation can be particularly helpful in those with a longstanding ‘sense’ of being unattractive or uncomfortable (Kennerley, 1996).

Another experiential technique is schema dialogue (Young et al., 2003), where a client conducts a dialogue between the old, unhelpful belief system and the more adaptive one.

In a session, Rosie’s therapist played the part of her assumption that she was ugly, and Rosie rehearsed responding with compassionate, positive statements that supported the belief that she was attractive. Initially, the therapist modelled arguments to undermine the validity of the negative perspective, but Rosie was soon able to take on this role and, in debate, became adept at generating convincing arguments that she was attractive.

To help the client in the early stages of challenging, Young et al. (2003) advise the use of schema flashcards that summarise the process for the client. These essentially prompt a client to use a problem feeling (anger, angst, urges etc.) to cue reflection on what makes sense of the feeling, and what they might do about it.

Rosie’s schema flashcard reflects a modified, brief version of Young’s format.

Right now I feel: ……………………………..

It is no wonder because: ……………………

However: ………………………………………..

Therefore I will: ………………………………

Rosie carried her card with her and when she was distressed used it as a reminder to pause, recognise what was happening and think what would be best for her. For example, she was very agitated driving home one evening and headed off to the garage to buy [a lot of] chocolate. She pulled into a parking bay and took out her schema flashcard.

Right now I feel:

Agitated and fragile. I want to binge this feeling away.

It is no wonder because:

I think I really messed up at work and I’m so ashamed. It makes me hate myself.

However:

This is my negative schema kicking in, making me assume the worst and feel bad. It’s my old view of myself and I have begun to learn to appreciate that I am a reasonably capable and okay person.

Therefore I will:

Not try to eat my way through this distress. I’ll put on some lively music, remind myself of my achievements and I’ll see if I can get through this without resorting to a binge.

By doing this, Rosie decentred, became aware of the schema-activation that was driving her feelings and urges, she challenged her unhelpful automatic thoughts and set up an experiment for herself.

Table 17.1    Classic and schema-focused CBT strategies

‘Classic’ CBT

Schema-focused CBT

Collecting data as part of a behavioural experiment

Positive data logs

Identifying dichotomous thinking and recognising

Continuum or scaling technique

gradations

 

Thought records

Historical log

Questioning blame

Responsibility pies

Role play

Psychodrama

Simple imagery transformation

Transformation of meaning of early memories; complex imagery transformation

Physical techniques

Body-image transformation

Challenging unhelpful thoughts

Schema dialogue

Progress review

Core belief logs

Aides-memoire

Schema flashcards

 

 

The techniques used to address fundamental beliefs are predominantly developments of ‘classic’ CBT strategies and are summarised in Table 17.1.

The experiential techniques have been shown to be particularly effective in achieving schemalevel changes (Arntz & Weertman, 1999). However, they can be very evocative of strong emotion and should be used with caution, i.e. only when clearly justified and when you are confident that your client can tolerate the consequent affect.

The more ambitious aims of schemafocused work often make it necessary to offer clients longer therapy – sometimes several years (Young et al., 2003). Thus, you need to ask not only ‘Have I the skills to engage in a schemafocused therapy?’, but also ‘Can both the client and I commit to a longterm intervention?’

It is striking that schemafocused therapy achieved popularity in the world of cognitive therapy, and across a range of disorders (Riso et al., 2007), without a substantial empirical foundation. There have been single case reports (e.g. Morrison, 2000), examination of specific schemachange methods (e.g. Arntz & Weertman, 1999) and open clinical trials (Brown, Newman, Charlesworth, CritsChristoph & Beck, 2004), but only relatively recently have we seen the outcome of randomised controlled trials. In 2006, GiesenBloo et al. published a study which showed that, over a threeyear period, Young’s Schema Therapy was superior to transferencefocused psychotherapy with patients with borderline personality disorder (BPD). In the same year Davidson and coworkers published the results of a shorter study (one year treatment and one year followup) where schemafocused CBT was combined with treatment as usual (TAU). Again, this study concentrated on patients with BPD and the results showed superiority for the combined intervention over TAU. Although the two interventions were different – in that one used Young’s Schema Therapy (2003) while the other combined a more Beckian schemafocused CBT approach (1990) – they each produced compelling results. However, it has to be borne in mind that both studies focused on a very specific population, so we cannot assume that the results would generalise to nonBPD populations. The same can be said for a more recent RCT that has also concentrated on clients with BPD (Farrell, Shaw & Webber, 2009). This study investigated the impact of adding 30 sessions of schemafocused group therapy (SFT) to TAU. The results again indicated significant improvement in functioning of participants in the SFTTAU group over the TAU group.

In summary, although schemafocused interventions might be theoretically justifiable and clinically defensible with BPD clients, schemafocused approaches should be used with thoughtful caution with nonBPD populations. We would suggest that traditional CBT should be the first choice for a client who has been assessed and considered suitable for cognitive therapy.

Compassion-based therapy

What is it?

A commonly reported emotion among those seeking psychotherapy is shame (Gilbert & Andrews, 1998). For example, it has been associated with depressive disorder (Gilbert, 1992), and eating disorders and childhood abuse (Andrews, 1997). There is evidence that those who are highly selfcritical do less well with traditional CBT (Rector, Bagby, Segal, Joffe & Levitt, 2000), and the explanation might lie in the nature of longstanding negative schemata. Compassionbased therapy aims to help those with internal shame, selfcriticism and selfcondemnation develop compassion towards themselves and thus reduce or eliminate their feelings of shame.

Shameful clients often adopt the techniques of cognitive therapy but fail to feel an emotional shift, because shame and selfcriticism pervade their responses. One reason might be that they use a harsh tone when challenging unhelpful cognitions. This can perhaps be likened to a parent ‘comforting’ a child by saying ‘Don’t be afraid’ in a stern tone, as though fear is ridiculous and contrasting this with a parent who uses the same words but with a tone of empathy and genuine caring.

Gilbert’s (2005) approach combines familiar cognitive behavioural interventions with compassionate mind training directed at addressing selfcriticism and shame. This combines the technical aspects of cognitive reappraisal with developing an attitude of caring and concern.

Social mentality theory

Compassionate mind training is based on Gilbert’s social mentality theory (1989), which proposes that selfrelevant information is often processed through systems (‘social mentalities’) that were originally evolved for social relating. Thus, each of us has an internal relationship with the self, and our thinking and feelings can reflect this ‘selftoself’ relating. For example, a person can be selfattacking and feel attacked, or a person can feel needy for care and be selfsoothing. Compassionbased therapy focuses on this internal relationship, training clients to develop inner compassion and warmth so that they might selfsoothe and counter selfattack effectively.

Compassion-based therapy in practice

Compassionbased therapy shares many similarities with classical CBT. A sound therapeutic relationship is crucial to therapy. The therapist uses guided discovery and thoughtmonitoring to identify key cognitiveemotional processes that relate to feelings of shame and to selfcriticism. A formulation is shared and, through this, patterns are identified, as well as blocks to therapy such as beliefs like: ‘Selfcriticism is good for me: it is character building’. The shared understanding of how the problem developed and why it persists allow what Gilbert calls ‘deshaming and deguilting’ (p. 287), which is similar to Linehan’s (1993) concept of validation. He advocates using imagery to capture the experience of being cared for, thus promoting feelings of acceptance, safeness and selfsoothing. This compassionate state of mind is then used to promote a compassionate reframe of unhelpful automatic thoughts.

Compassionbased therapy uses experiential interventions, many similar to those employed in the schemafocused treatments. Techniques include promoting imagery of the compassionate self and restructuring past, traumatic experiences; achieving a detachment from the emotional impact of NATs by learning to name the critical process; and developing inner dialogues with the hostile self – sometimes using the Gestalt twochairs technique. Compassionate meditations are also advocated, with similarities in form and purpose to the mindfulness exercises of DBT and MBCT (see below).

Compassionate mind training is a relatively ‘young’ psychotherapy, but its popularity is growing (see Gilbert & Irons, 2005, for a review), and the approach has been adapted for the treatment of depression (Gilbert, 2005), PTSD (Lee, 2005) and anxiety disorders (Bates, 2005; Hackmann, 2005). Although theoretically strong, the empirical argument for CMT in clinical practice remains less powerful. There are uncontrolled trials (e.g. Gilbert & Proctor, 2006) and case series (e.g. Mayhew & Gilbert, 2008) to support its use but, as yet, no RCTs to endorse the intervention. This is not to say thatthe approach is not effective but that it should be employed with the cautions and reservations previously suggested when considering schemafocused approaches.

Mindfulness-based cognitive therapy (MBCT)

What is it?

This novel treatment approach was developed as a relapseprevention intervention for depression (Segal et al., 2002). It combines elements of classic cognitive therapy with ‘mindfulness’ training, a therapeutic meditation approach developed by KabatZinn (1994), who described mindfulness as ‘paying attention in a particular way: on purpose, in the present moment and nonjudgementally’ (KabatZinn, 1994, p. 4).

As far back as 1995, Teasdale, Segal and Williams proposed an alternative to the assumption that CBT was effective because of changes in belief in the content of negative cognitions. They suggested that CBT might work because, by prompting clients to pause, identify cognitions and evaluate the accuracy or usefulness of their content, it helps them ‘stand back’ from problem cognitions. This allows ‘distancing’ or ‘decentring’. Teasdale, Moore, Hayhurst, Pope, Williams & Segal (2002) highlighted the importance of decentring and increased meta-cognitive awareness as an effective intervention in reducing relapse in depression.

This raises the possibility that relief from psychological distress might be achieved by helping clients switch to a state of mind in which unhelpful thoughts and feelings are viewed from a decentred perspective. As the meditative stance of mindfulness training enhances decentring, mindfulness was incorporated into CBT, and MBCT was developed.

Interacting cognitive subsystems (ICS)

MBCT is based on a model of informationprocessing known as interacting cognitive subsystems (ICS), which regards the mind as a collection of interacting components (Teasdale & Barnard, 1993). Each of these components receives information from the senses or from other components of the mind. Each component then processes this information and passes the transformed information to other components. Thus, there is an interacting network within which recurring patterns appear in response to certain stimuli. In particular, those with previous experiences of depressive disorder get caught up in escalating selfperpetuating cycles of cognitive–affective ruminations more readily than those without a history of major depression. This pattern of rumination increases the likelihood of relapse into depression (Teasdale, 1988).

Teasdale calls the recurring patterns of interaction between mental components ‘modes of mind’ and likens them to the gears of a car:

 

Just as each gear has a particular use (starting, accelerating, cruising, etc.), so each mode of mind has a characteristic function. In a car, change of gear can be prompted either automatically (with an automatic transmission, by a device that detects when the engine speed reaches certain critical values) or intentionally (by the individual consciously choosing to rehearse a particular intention or to deploy attention in a particular way). (Teasdale, 2004, p. 275)

He goes on to say that, just as with a car, the mind cannot be simultaneously in two gears or modes. Thus, operating in one mode of mind precludes a person from being in another state of mind at the same time. MBCT aims to help clients recognise a ‘mental gear’ which is unhelpful, to disengage from it and to shift to a more functional cognitive mode. Mindfulness is seen as an alternative and helpful cognitive mode, as it is the antithesis of rumination. Depressive rumination is characterised by repeatedly and automatically thinking about negative material, and mindfulness appears to decrease the likelihood of relapse into depression by putting the client into a state of mind that is incompatible with rumination, namely:

 

  • intentional: focusing on present experience rather than processing thoughts about the past or the future;
  • regards thoughts as mental events, rather than valid reflections of reality;
  • non-judgemental: viewing events as events, rather than ‘good’ or ‘bad’;
  • fully present: that is, experiencing the moment, which reduces cognitive and experiential avoidance.

MBCT in practice

MBCT is a manualised group skills training programme for clients in remission from recurrent major depression (Segal et al., 2002). It integrates mindfulness with compatible elements of CBT. However, there is little emphasis on changing unhelpful thoughts but rather on cultivating greater mindfulness with respect to them. The key to this is achieving a stance of nonjudgement and radical acceptance. MBCT aims to help clients become more aware of, and to relate differently to, their cognitive, emotional and physical experiences. Clients are taught to disengage from habitual and dysfunctional cognitive routines as a way to reduce future relapse and recurrence of depression.

Groups meet weekly for eight twohour sessions, with homework assignments between meetings. These take the form of awareness exercises and tasks designed to integrate the application of awareness skills into daily life. Following the initial eight meetings, followup sessions are scheduled at increasing intervals.

Two RCTs have evaluated the effects of MBCT for recurrent depression, and shown a 50% reduced risk of relapse. In a recent randomised controlled study, Kuyken et al. (2008) showed that, over a 15month followup period, MBCT is as effective in preventing relapse as antidepressant medication. More recent small studies (e.g. Barnhofer, Crane, Hargus, Amarasinghe, Winder & Williams, 2009) are indicating that it is also effective in reducing symptoms in patients with chronic depression. So far, the results of trials indicate that MBCT is a costefficient preventative programme that can reduce the risk of relapse and recurrence in those with three or more previous episodes of depression. It is also being used to help sufferers of other problems such as bipolar disorder, chronic fatigue, insomnia, GAD and cancer, and we can look forward to a continued refinement of the model and further clinical trials.

Other metacognitive therapies

What are they?

As we have seen, in earlier chapters, metacognitive awareness is the capacity to experience thoughts and images as cognitions, simply events in the mind, and its therapeutic advantages have been applied to other developments of CBT in addition to MBCT. It is part of ACT and DBT (see below) and in 1995 Wells introduced the idea of Metacognitive Therapy (MCT) for anxiety disorders and later (2008) for both anxiety and depression. The theoretical grounding for this clinical approach is the Selfregulatory Executive Function Model (SREF: Wells & Mathews, 1994), which proposes that psychological disorder is underpinned by Cognitive Attentional Syndrome (CAS), which comprises:

 

  • worry and rumination
  • threat monitoring, and
  • unhelpful coping behaviours.

The MCT approach teaches:

 

  • ‘detached mindfulness’,
  • ‘attention training’, and
  • ‘situational attentional refocusing’.

These strategies aim to enhance a person’s metaawareness of cognitions, change the relationship with the cognition and address beliefs about the utility and necessity of worry, rumination and threat monitoring. Rather than attempting to modify the content of the NAT or schema by considering its validity, it addresses the content of the metacognition and the way in which thoughts are experienced and regulated.

MCT has been evaluated in several open trials and case series and in one small RCT where it proved superior to a notreatment waiting period (see Wells (2008) for a review). Thus, its superiority to classic CBT is not yet well proven.

The radical behavioural interventions

What are they?

Some practitioners and researchers have developed cognitive behavioural interventions that have a clear cognitive component but emphasise the importance of the behavioural aspect of treatment. These include Linehan’s dialectic behaviour therapy (1993), acceptance and commitment therapy (Hayes, Strosahl & Wilson, 1999), and Jacobson’s behavioural activation (Martell, Addis & Jacobson, 2001). Below is a brief summary of each of these increasingly popular approaches.

Dialectical behaviour therapy (DBT)

Linehan, Heard and Armstrong (1993) devised this intervention specifically for parasuicidal women diagnosed as having borderline personality disorder (BPD), a diagnosis associated with poor treatment outcome. DBT comprises a broad array of cognitive and behavioural strategies, tailored to address problems associated with BPD, including suicidal behaviours. The core skills taught are:

 

  • emotion regulation
  • interpersonal effectiveness
  • distress tolerance
  • mindfulness, and
  • self-management.

Treatment requires both individual and group sessions to run concurrently.

The defining characteristic of DBT is an emphasis on ‘dialectics’ or the reconciliation of opposites – for example, achieving selfacceptance whilst recognising the need to change, or balancing the alternating high and low aspirations which are common in those with BPD. Together with this focus on dialectical processes, there is more emphasis on process than on structure and content.

DBT differs from CBT in several other respects. Rather than aiming to challenge, it promotes acceptance and validation of the client’s behaviour and reality. The therapeutic relationship is deemed central to DBT, and there is an emphasis on identifying and addressing therapyinterfering behaviours.

DBT has now been evaluated in several trials comparing it with treatment as usual (for example, see Bohus et al., 2004). Overall, it is associated with better retention rates and is effective in reducing selfharmful behaviours. Although DBT appears to diminish a particularly dangerous behaviour, so far its effectiveness seems quite specific, and it does not necessarily target the wide range of problems suffered by many clients with BPD.

Acceptance and commitment therapy (ACT)

ACT assumes that psychological problems are due to a lack of behavioural flexibility and effectiveness, and the goal of therapy is to help clients choose effective behaviours even in the face of interfering thoughts and emotions. Therapy is based on Hayes’s relational frame theory (Hayes et al., 2001), which views psychological problems as a reflection of psychological inflexibility and experiential avoidance. The model has two main components: acceptance and mindfulness processes and commitment and behaviour change processes – hence, ‘acceptance and commitment therapy’. In ACT, these processes are balanced to produce greater ‘psychological flexibility’ (which Hayes views as the ability to experience the present moment fully as a conscious, historical being) and, depending on the situation, changing or persisting in behaviour in the service of chosen values.

Therapists are advised to adopt a compassionate attitude towards the client, echoing Gilbert’s therapeutic guidelines. Hayes also emphasises the importance of being in the present moment, advocating the therapeutic use of mindfulness, echoing MBCT and DBT.

To support ACT, there are several randomised controlled studies indicating its efficacy with, for example, psychotic symptoms (Bach & Hayes, 2002) and specific anxiety disorders (Zettle, 2003).

Behavioural activation (BA)

Behavioural activation emerged as a standalone treatment for depression following a component analysis study of CBT (Jacobson et al., 1996). BA was found to equal in efficacy a more complete version of CT, which also incorporated coping skills to counter depressive thinking.

BA helps depressed people reengage in their lives through focused activation strategies. This counters patterns of avoidance, withdrawal and inactivity that may exacerbate depressive episodes by generating additional secondary problems. BA is also designed to help clients reintroduce positive reinforcement in their lives, which can have an antidepressant effect. This approach is also mentioned inChapter 12, which more fully details the role of activity scheduling in the management of depression. See Martell et al. (2001) for a full account of BA.

Neuroscience

What is it?

This is the study of brain function, and interestingly, in the past decade it has made an increasing appearance in the CBT literature (see Frewin, Dozois & Lanius [2008] for an empirical and methodological review of studies of the impact of CBT on the brain).

Theorists and practitioners seem to have become more interested in understanding emotional and cognitive reactions at a fundamental level. For example, Brewin (2001), and also Ehlers and Clark (2000), referred to brain mechanisms in describing their understanding of the formation of traumatic memories and in developing their models of PTSD. Gilbert’s Social Mentality Theory (1989) incorporates neurochemistry, Young et al. (2003) cite the importance of understanding neurobiology of the ‘emotional brain’ and make reference to LeDoux’s (1999) neurological findings. Researchers in MBCT are increasingly studying the neurophysiological effects of the training (e.g. Barnhofer, Duggan, Crane, Hepburn, Fennell & Williams, 2007).

Why is this interesting?

Cognitive therapists are interested in emotions and emotional processing: it is what we assess, address and monitor in our CBT sessions. It has long been known that basic emotional responses are generated by the primitive limbic system in the brain and in particular by the amygdala. Links from the limbic system to the cortices help to inform our emotional responses by ‘contextualising’ them (crossreferencing with previous knowledge) and different links to the highly developed prefrontal areas help us recognise and moderate our emotions. In 2008, Beck called for a better understanding of the neuroscience ofdepression and McNally (2007) for a better appreciation of the neuropsychology of the anxiety disorders. Both argued that an improved understanding of brain function can improve psychological treatments by giving us a more comprehensive understanding of psychological problems. But how?

A better understanding can inform our interventions, for example, we know that diminished prefrontal cortex functioning, correlates with poor emotional management. It is also associated with borderline personality disorder (BPD) (Berlin, Rolls & Iversen, 2005). It is no wonder, therefore, that clients with BPD can be impulsive and have difficulties recognising and managing emotions, and as therapists we need to take this into account and have realistic expectations of ourselves and our clients. Poor frontal lobe functioning is also associated with developmental trauma and this might help us better appreciate why some of our patients with traumatic childhoods struggle to cope with the very emotionally evocative imagery work or role play. We also know that enhanced functioning of these areas of the brain is associated with meditation (Lazar et al., 2005) and exercise (Colcombe et al., 2003), and that physical exercise also increases levels of the monoamines that can moderate mood and anxiety (Chaouloff, 1989), thus we can confidently encourage these activities in clients who are having initial difficulty engaging with the standard cognitive elements of treatment. It has been shown that fear circuitry (McNally, 2007) and depressive circuitry in the brain is robust (Bhagwagar & Cowan, 2007) which can help us understand a client’s vulnerability to relapse and help us appreciate the importance of relapse management work (see Chapter 6). Chronic stress causes shrinkage of the hypothalamus which impairs memory formation and recall – something you can compensate for by introducing memory aids into sessions.

These are just a few examples of how understanding some ‘first principles’ of brain functioning can help you enhance your psychotherapy. For researchers, understanding more about the different brain mechanisms for different disorders can inform both pharmacological, psychological or combination treatments – particularly in the more severe psychiatric disorders.

In conclusion

Since CBT emerged in the 1970s, researchers and clinicians have been striving to apply it more effectively and to a wider population. As a result we have now a range of CBTbased interventions we can adopt when working with a range of clients with differing needs and problems. However, we would urge you to consider carefully any departure from the evidencebased interventions and ensure that your understanding of your client’s difficulties justifies it.

Problems

The therapist is not competent to offer the therapy

Clinicians not only need to be familiar with the basic principles of CBT and the augmentations of it but need to be able to work with clients who might have challenging interpersonal difficulties and who might present with a range of problems – some dangerous to themselves and others. Thus, as a therapist, you need to be prepared to gain additional training and to ensure that this is combined with good supervision and support.

The therapist is stressed by the complexity and the demands of the therapy

The therapies described in this chapter tend to be reserved for complex clients who can be taxing on the therapist’s skills and resources. As indicated above, supervision is essential for therapists working with complex clients and additional peer support can also offset some of the stress (although support should be in addition to supervision and not instead of supervision). Nevertheless, therapists need to be realistic and only take on cases when they are reasonably confident that they can provide longterm or intensive care when necessary. It is also important to have a caseload with a ‘balance’ of clients that matches the therapist’s skills and resources. Kennerley et al. (2010) have written a useful and practical chapter that addresses coping with therapist stresses.

The case seems never-ending

Clients with complex needs can require ‘longerterm’ therapy, which, in the literature, can mean anything from 20 sessions to several years. In order to guard against unnecessarily prolonging therapy and to guard against fostering dependence, you are advised to use supervision and to review progress regularly with a view to ending therapy if there is little indication that cognitive therapy is helpful or necessary.

Vicarious trauma

Some of the more complex casework invariably involves working with clients who will describe traumatic events, and vicarious traumatisation can occur in therapists exposed to this (McCann & Pearlman, 1990). Good supervision and support can help you identify the early signs of vicarious trauma, such as experiencing traumatic intrusions or taking actions to avoid triggering them – actions such as drinking to numb emotions or suppress images. Good supervision and support can also be helpful in guiding you towards developing ideas for coping, and again, the recent chapter by Kennerley et al. (2010) mentioned above gives some advice on managing vicarious trauma.

 

Summary

 

  • Cognitive therapy has been used with an increasing variety of clinical populations and with client groups of increasing complexity and/or chronicity. This has demanded developments in cognitive therapies and augmentations of CBT and we have seen the rise of:

o    Schema-focused approaches: Young’s Schema Therapy and the ‘Beckian’ Schema Focused Cognitive therapy (SFCT)

o    The metacognitive approaches of CMT, MBCT and MCT

o    The radical behaviour therapies of DBT, ACT and BA.

  • It is interesting (and reassuring) that there are themes common to several of the newer approaches, including the relevance of schemata, of meta-cognitive awareness and of acceptance. There is also a zeitgeist of understanding the neurological processes underlying psychological functioning.
  • There can be no doubt that these developments have been exciting and have been met with enthusiasm. In general, however, the empirical status of some of the interventions is still poor and where there is empirical support some of the treatment trials are highly specific – for example, for BPD in the case of schema-focused approaches and for para-suicidal women with BPD in the case of DBT. Until there is further evidence, we cannot assume that the approaches will generalise to other populations and so they should be used with appropriate reservation.

Learning exercises

Review and reflection:

 

  • There are several distinct parts to this chapter, and each is very much a brief overview, so there is much scope for you to take your interests further. So, first consider which aspects are most relevant to you and take some time to review that section, making notes if you find it helpful.
  • When you have identified what interests you, ask yourself questions such as:

 

o    How does this actually relate to my clinical practice and my clients’ needs?’

o    How does this fit with my way of working?’

o    How does this relate to my supervision or research opportunities or interests?’

o    Can this new approach really enhance my client’s treatment?’

o    What advantages will this approach have over classic CBT?’

  • Ask yourself: ‘Is there enough theoretical support or empirical data to justify my adopting a new way of working?’ and review your client’s formulation to see if your case conceptualisation indicates novel approaches.
  • Are you sure that you have used ‘classic’ CBT to the best of your ability – have you given it a reasonable chance?
  • Be critical and realistic in your thinking: don’t be tempted to adopt a new approach just because it seems attractive.

Taking it forward:

 

  • If you have decided that you will take up some of the ideas in this chapter, consider how you will ensure that you develop your knowledge and skills. The first step might be more reading or attending training or finding a specialist supervisor. This will require some groundwork as training opportunities might be relatively rare. You also need to find the time (and the money) to do this. So make some concrete plans for securing the resources and set yourself deadlines for starting this project and for taking stock of your progress.
  • It can be helpful to see if a colleague is also interested in learning more about the developments in CBT as you can ‘buddy’ each other and provide support and encouragement.
  • Evaluate your interventions. It is always good practice to develop ways of assessing the impact of your therapy and it is even more important to do this when you are using approaches that are relatively new or, as yet, have little empirical foundation.

Further reading

The CBT Distinctive Features Series (Ed. Windy Dryden). Hove: Routledge.

This series includes recently published texts covering all the developments which have been mentioned in this chapter, with the exception of neuroscience.

Gilbert, P. (2005). Compassion: conceptualizations, research and use in psychotherapy. Hove: Routledge.

The first CMT ‘manual’ which invites expert contributors to detail CMT interventions within specific clinical areas. This text contains a great deal of clinical wisdom and practical guidance.

Riso, L.P., do Toit, P.L., Stein, D.J., & Young, J.E. (2007). Cognitive schemas and core beliefs in psychological problems. Washington, DC: American Psychological Society.

This is a useful comprehensive volume which considers the application of schema-focused interventions across a range of psychiatric presentations. The contributors to the book are experts in specific fields and describe the potential for using schema-focused approaches with wise caution. The text is rich in clinical illustration.

Segal, Z.V., Williams, M.J.G., & Teasdale, J. (2001). Mindfulness-based cognitive therapy for depression: a new approach to preventing relapse. New York: Guilford.

This is the basic text for MBCT practitioners. It is very clinician-friendly, thoughtfully and clearly presented with a systematic overview of a course of MBCT for recurrent depression.