Cognitive-Behavioral Approach to Therapy

The cognitive-behavioral approach (known as CBT) is actually a collection of various techniques in psychotherapy.   They are primarily identified by the fact that they take a very ‘practical approach’ to the counseling relationship as opposed to Jungian or Freudian analysis, or even Rogerian work which is highly person-centered therapy.  

CBT is known for its focus on person’s behaviors and developing contracts that are highly practical in nature and focused on very specific goals for both client and counselor.   One of the primary theoretical approaches of CBT is that behavioral and/or personal dysfunction is a ‘learned response’, that is, it is most often the result of the way we have learned to behave over the year.   Thus, dysfunctional behavior is often viewed as a   pattern of learned responses.   The other aspect of CBT’s theoretical approach is that if behaviors can be learned, they can be ‘unlearned’.   CBT therapists work on the premise that patterns of behavior can be reversed when people learn to challenge their core beliefs.   For example, if a person believes they are a victim of circumstances in life, then they will assume the behaviors of someone who has been victimized.   As such, they must unlearn these behaviors by challenging the situations and circumstances that led them to believe this in the first place.   “[…] the cognitive-behavioral approach to treatment is guided by an experimental by an experimental orientation to human behavior, in which any given behavior is seen as a function is seen as a specific environmental and internal conditions surrounding it […] The cognitive-behavioral therapist approaches treatment with the assumption that a specific central or core feature is responsible for the observed symptoms and behavior patterns experienced […] once the central feature is identified, targeted in treatment, and changed, the resulting maladaptive thoughts, symptoms and behaviors will also change” (Hazlett-Stevens & Craske, 2003).  

Reality therapy is a technique pioneered by California-based psychiatrist, William Glasser.   Most recently, he updated this theory and now calls it ‘Choice Theory’ (CT).   Glasser has openly stated that he is strongly opposed to traditional psychoanalysis and wrote a book about the subject.   Much like other aspects of CBT, Glasser’s Choice Therapy is very much rooted in the here and now.   In his own words he states that; “People love to go into their past and talk about how they didn’t get along with their mother and father and grandfather. They love that because it allows them to avoid facing the real problem that is going on right now” (Clark, 2003).   Much like it sounds, CT is about the choices we make in life, why and how we make them and whether or not we’re ready to take responsibility for them.   In fact, Glasser goes so far as to suggest that people actually choose insanity, or depression.   Glasser is also strongly opposed to medications for psychiatric problems as he feels they actually impair a person’s ability to live a healthy life. “Choice Theory explains that we choose everything we do. From birth until death, all any of us do is behave. All behavior is chosen. I don’t talk about responsibility that much any more because it’s already built into the system. Everyone’s always responsible for what they do” (Clark, 2003).   CT is strongly rooted in the premise that people can help themselves, but they must choose to do so.  

Operant conditioning is a phrase that was coined by B.F. Skinner.   Operant behavior is probably most easily described as ‘habit’, that is, habits that we adopt over time and become automatic to us as individuals.   Operant condition then, is the reversal of this process.   Like CBT and CT, it is a highly intellectual process and one which takes on the habits, behaviors and thought processes that become part of peoples’ everyday lives. However, Skinner’s premise is that these behaviors must be systematically attended to and not simply discussed in the counseling room.   “Operant conditioning differs from other kinds of learning research in one important respect. The focus has been almost exclusively on what is called reversible behavior, that is, behavior in which the steady-state pattern under a given schedule is stable, meaning that in a sequence of conditions, XAXBXC …, where each condition is maintained for enough days that the pattern of behavior is locally stable, behavior under schedule X shows a pattern after one or two repetitions of X that is always the same” (Staddon, 2003).

In many ways, Rational-Emotive Therapy (RET) is much like choice therapy although it varies to some degree. This technique was pioneered by Ellis and also focuses on peoples’ cognitive process as a means of creating dysfunction in their lives.   Thus, the beliefs we assume, our choices and our behaviors are all strongly and intricately connected.   In order to change one, we must begin at the source and to RET practitioners, this is the thought process.   In 1999, Dr. Stephen Palmer interviewed Dr. Albert Ellis who spoke at length about RET.   As a practicing psychotherapist at the time (1955). The premise for his work is that people tend to use two techniques for coping with stress.   The first is distraction and the second is to panic and focus on how ‘awful life is’.   In addition to this, he believes that people pile on even more stress by focusing on how much they panic and react with horror to their ‘awful situation’.  

Ellis believes that the first strategy is to help people calm down by using relaxation techniques such as yoga and meditation, although he also believes these are primarily distractions.   The second stage is to point out how many “shoulds” and “ought to” people are flooding their minds with.   In his own words; “Distressed people can directly dispute their self-disturbing musts – can do so after they use suitable relaxation techniques” (Palmer, 2003).   Ellis goes on to say:  

Using REBT, we show each individual how to dispute masturbatory beliefs, ask `Where is the evidence that I must do well?’; `How does it follow that if I do poorly I’ll always fail, never succeed?’; `Prove that I’m a bad person for acting badly in this situation?’ We dispute logically and empirically and pragmatically the demands that people are making to create their real distress about stressors. We show them how to stop horrifying themselves about their stressor (Palmer, 2003).  

Much like other techniques in CBT, RET is about disrupting the inner dialogue that takes place which provides people with a sense of who they are and how they are this world.   RET proposes that this disruption is the first and quintessential stage in not only changing the way people behave but the way they see themselves.   RET is very much about changing self-perceptions and not just changing behaviors. According to this theory, people fill their heads with limiting and self-destructive thoughts all the time. Eventually these self-defeating thoughts break down the body and stress takes over.   At that point people become overwhelmed. “So we try to get distressed people to see what they’re doing to upset themselves, distress themselves about stressors. But as we do this we go back to the stressor, the activating event, and try to see if they can really do something to change it, improve it, or get rid of it. This may consist of all kinds of practical solutions, like doing better at work, getting a new job, talking to one’s co-workers” (Palmer, 2003).   This quote demonstrates that RET has a very practical component to it and that is active change.   Ellis is a strong proponent of making real change in one’s life in order to disrupt the negativity which takes over many peoples’ lives.   For example, if a person is unhappy at work, the core issue must be found first and then it must be dealt with.  

CBT is also highly practical in nature in that it encourages self-help and brief counseling treatments, not long-term analysis or therapy as promoted by other psychotherapeutic techniques.   One of the most important components of CBT and in fact, all of these approaches is the work of the client.   This type of practical approach assumes, in many ways that the client is a highly motivated individual who is in the counseling relationship in order to affect change and not simply talk about or complain about life’s circumstances.   “[…] CBT puts a greater burden on the patient to engage actively in treatment both during and between sessions.   The CBT patient assumes much responsibility for learning necessary therapeutic material, and practice of relates exercises and skills […]”(Hazlett-Stevens & Craske, 2003).  

CBT’s focus on brief counseling (usually identified as 10 sessions but sometimes more) means that the entire process is highly focused on attaining very set and specific goals.   With respect to my emotional reaction to this approach, my first reaction is this is not a therapeutic approach for everyone, but then it is highly unlikely that any approach is.   I feel this is an approach for individuals who are highly intelligent, strongly motivated to change and persons who are practically minded.   None of these approaches seem to be centered on the emotional needs of the client so much as their practical needs.   Further to that, they are also approaches which focus on the cognitive and not the emotional state of the client.   Thus, everything seems to be about the client’s way of thinking as the source of their behavior.   I wonder therefore, how they would deal with extreme situations such as the sexual assault of a child or the survivor of war/trauma.   How can we say in either of these situations that it is their thought process that causes their distress or depression?  

On the other hand, I feel there is some value in this approach for people who are not highly traumatized but seeking practical change in their life.   I sense any of these approaches would be helpful if someone wanted to challenge their sense of self-esteem or the choices they’ve been making in life (or their pattern of choices).   I sense that there would be value in using CBT in the process of making a difficult or new career choice, especially since it requires the client or patient to be an active partner.   However, for someone who suffers with clinical depression, I question whether 10 sessions would be of value.   In addition, most people who cope with clinical depression suffer from low motivation and therefore might likely find it extremely difficult to be such an active partner, especially in the beginning.  

In terms of theoretical premises, I strongly question Dr. Ellis’s assumption that people choose depression or insanity.   His example (as quoted in the interview) was that of Dr. John Nash, whom he claims ‘chose insanity’ after losing a chance at the Nobel Prize.   The fact is, Dr. John Nash had been exhibiting symptoms for years and was never close to the Nobel Prize until much later in life.   Dr. Ellis goes on to state that Nash “chose sanity” after he won the Nobel Prize (Palmer, 2003).   I find this to be clinically unsound and highly unlikely that winning the prize would be able to cure someone who was formally diagnosed with paranoid schizophrenia.  

To some degree, I agree with B.F. Skinner when he theorizes that peoples’ behaviors are often the result of habit and maladaptive habits in particular.   The fact is, I feel our emotional reactions are often more out of habit than they are out of truly thinking or feeling a situation completely.   I also agree with the premise that people can and adopt self-defeating behaviors triggered by negative thought processes.   However, I ask myself the question; “how and when did these negative thoughts begin?”   “Why is this person thinking negatively?”   Another example might be a young man or woman who engages in negativity as a result of having been verbally and or emotionally abused by parents or others.   Have they assumed these negative thoughts or have these thoughts been ingrained in them by others?   This is the question I believe any therapist must ask and answer before choosing an approach with a client.  

In terms of Glasser’s approach, I agree with some of his premises and disagree with others. While I agree that people can get mired down in the bog of talking about past issues and problems; sometimes they are the essence of the situation.   I don’t see how a therapist can ignore a past trauma or abuse.   On the other hand, I also feel, as Glasser asserts, that some clients can truly use their past as a means of avoiding what is taking place in the present.   I feel that to some degree it’s not what’s happened in our lives but how we deal with this; I also feel there are exceptions such as a gang rape or the Holocaust and other extreme examples.  

In the final analysis, I would have to say that I don’t agree that CBT is for everyone, nor do I think it’s for people with serious traumas.   The reason I say this is if we suggest that our thought are responsible for everything, then we are negating the fact that external factors are a big part of our lives.   The fact is, parents, teachers and siblings can impact on children.   Peers and parents influence teenagers and employers and colleagues affect us adults.   The country and culture where we live are additional factors in our lives. I simply do not accept the theoretical premise that everything is about the cognitive process. While I believe it’s a factor, I also feel and strongly so that our emotions are not only about our thoughts. I think our emotional responses are highly complex and the result of both conscious and unconscious assimilation of the events and people in our lives.   I feel that by ignoring our emotional responses and suggesting that everything is triggered by conscious thought which leads to negative patterns is simplifying the human mind and its connection with our emotions.  

I also feel that not everything in life is by choice. On this matter, I strongly disagree with Dr. Ellis.   I don’t believe that a child or even an adult woman who is raped is sad, frustrated, depressed or angry by choice. I think it’s a logical and true emotional response to a horrible event.   At the risk of overstating my point, I also feel it’s a natural response.   Ellis’ point appears to be either get rid of it, change it or improve it. In such an event, I don’t think these are possible.   Therapeutically, I think it’s healthier to take a Rogerian approach — deal with the emotions that you experience in the moment.   Learn to understand how you feel and why. Learn to acknowledge and accept your emotions and own them.   To me, this would be a much healthier therapeutic response.  

I also feel it is a challenge to use CBT for people from a broad range of cultures. The primary problem is that peoples’ belief systems and values (cultural and spiritual) vary widely.   Often times peoples’ thought process or their sense of self are guided by these values.   Scorzelli and Reinke-Scorzelli (2001) studies the use of CBT in other cultures.   Their research demonstrated that graduate students in India felt that CBT conflicted with their cultural values.   The researchers moved on to Thailand to see if this assumption was true for other cultural groups.   They concluded the following: “The participants in the India study felt that the cognitive approach to counseling conflicted with their values and beliefs (Scorzelli & Reinke-Scorzelli, 1994), while the Thai group felt that cognitive therapy was consistent with their religious and cultural beliefs. Furthermore, although there was no trend identified in the reasons given by the students in India, the participants in Thailand indicated that their belief in Buddhism was the major reason that cognitive therapy was consistent with their culture.”   In the end, these authors stated that counselors need to be “cautious” about tailoring their counseling to specific cultural values and attend to the person’s issues.  

From a counseling perspective, I think this can work both ways.   On the one hand, I can see it as valuable that a counselor take the time to understand the cultural perspective the client is ‘coming from’.   For example, a woman in the Muslim faith may have to deal with certain cultural and spiritual expectations as would an Orthodox Jewish woman.  

I don’t see how can the counselor separate these from the counseling of these individuals.   With respect to individuals who are gay, lesbian, bisexual or transgendered, I could actually see CBT as an extremely helpful process. The process of ‘coming out’ for example is often one of challenging the beliefs people (friends, family, peers) may or may not have about homosexuality.   A person may have fears of telling people they’re gay but they may be unfounded. On the other hand, a person who deals with gay bashing may find that CBT provides them with practical strategies for coping with a highly difficult and stressful situation. It is possible that CBT could identify specific ways of communicating and dealing with potentially harmful situations.   Yet, I believe there is one cautionary tone here.   Gay people are often the target of tremendous hate and discrimination.   Personally I don’t see how this can be a choice for someone to have to endure this. Yet they do.   From a therapeutic perspective, again I think a Rogerian approach would be far more helpful.  

As with all therapeutic approaches, CBT is not for everyone, nor is it for every situation. In the long run, it is a highly practical approach which demands an engaged and motivated client; someone who is seeking immediate change.

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