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Third wave developments in cognitive-behavioural approaches to theory and practice

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Describe the central elements of the cognitive-behavioural approach, including reference to some third-wave developments in theory and practice.

In this essay, the central elements of the cognitive behavioural approach and third wave developments will be reviewed. The central elements will be referred to as the claims of the approach, as research is continuous and has changed through time. CBT alters the cognitive process to resolve maladaptive behaviours and psychological distress. These alterations change cognitive thinking patterns and behavioural reactions.(Stallard, P. 2002)The CBT approach claims that a behavioural reaction to a situation is determined by our perception of them, not the situation itself. CBT benefits from the client-therapist relationship through genuineness, empathy and understanding while changing this perception. It claims to enable the client to become his or her own therapist to monitor and address their own maladaptive processes through behavioural or philosophical (third-wave) coping techniques. This essay will explore these elements (claims) through CBT’s approach to treatment and associated research through critical discussion.

Treatment

CBT addresses the client’s treatment objective and has a structured approach to assessing, treating, monitoring and evaluating the client. The treatment aims to alter perceptual thinking patterns, and this process is formulated with clear definitions and frequent reviews. Moreover, CBT is not time -consuming as the treatment only takes 16 sessions with a therapist, therefore it actively encourages the client to become independent and make use of self-help coping techniques. These can include journaling, cognitive-restructuring, relaxed breathing and many more. It is also not distressing, as these techniques promote relaxation; therefore, it can be considered a universal treatment for children and adults.

Spitzer created the Diagnostic and statistical manual of mental disorders as a framework for diagnosis which details how CBT should be implemented. The DSM claims to be methodologically meticulous in over ‘ 12, 000 clients and 550 therapists in 212 facilities’(Spitzer, 1980), yet there is no evidence for this impressive claim. DSM guidelines allow psychologists to investigate individual cases and coordinate self-help coping techniques which will fulfil the treatment needs of the patient which is useful. (Barlow et al. 2017). But, by promoting a positive ‘ fulfilment’ at the end of the treatment process, CBT often oversells itself which leads patients to expect a universal approach and an ‘ off the shelf’ type treatment. Moreover, by classifying mental illness in terms of ‘ coping’ CBT does not focus on the cause of the issue, it only poses maintenance mechanisms. The lack of long-term effectiveness and research support means that CBT has become diluted, therefore critics (Binnie. J., Spada. M. M., 2018) question it as a method of psychotherapy

Through semi-structured interviews, clients can reflect on their own thoughts and express their incongruence through self-talk which can be formulated from the age of three in an interview setting (Hughes, 1988). This is useful as it poses the CBT approach has the potential universality. Yet, Whitaker, (2001) suggest a child’s mind is still developing, therefore the cognitive behavioural tasks need to be expressed at the appropriate level. This can be done by using simplified language, visual information and presenting abstract concepts as concrete ones. Not only would this make CBT better for children but those with cognitive and behavioural disabilities. This is not a complete limitation as it poses a direction for cognitive behaviour research. It highlights the possibility of universality within treatment, even for those most vulnerable. Interview questions should promote thought and increase understanding rather than demanding a ‘ correct’ response. (Neenan. M & Palmer. S 2018) Therefore, a pre-planned defined session, with a ‘ correct’ response before the problems are explained and identified is over simplistic. (Goldfried, 1995).

A modern CBT approach poses that the treatment outcome, factors in session processes (DeRubeis et al. 2017) and by implementing these factors into testable models, it enables a better understanding of how CBT treatment devices work for the patient and the therapist. This is true with Kazantzis’ (2017) research on the initial Cognitive Therapy Scale’s interpersonal items.  These items: feedback, collaboration, interpersonal effectiveness and guided discovery are useful for classification, and they have multimodality. For example, guided discovery could be induced through a client-therapist relationship or by self-help techniques, which makes treatment adaptable. This contradicts Goldfried (1995’s) criticism, so within the approach, what is scientific fact and what is a claim is ‘ muddled’.

Research

More recently CBT, claims a holistic approach which tailors’ therapeutic techniques to the needs of the client. Research support meets the rigorous criteria of an empirical treatment through strong comparative conditions. In Cuijers (2016) study he found that 17 % of depression and anxiety trials were of high quality. Most psychotherapy approaches are far from these numbers in current trials and study quality therefore cognitive behavioural therapy can be considered the gold standard of psychotherapy. (David. D., et al 2018) CBT is considered ‘ gold’ as it is well researched and systematically innovative, and its theoretical models align with the contemporary paradigms of cognition and behaviour. Moreover, there is room for advancement in the CBT process, by making their theories more adaptable it could turn this ‘ holistic’ claim into a testable treatment process.

CBT still has the most research support to validate its underlying theoretical claims. Whereas some psychoanalytical treatments are controversial, lack research support and some are only emerging e. g. interpersonal psychotherapy. CBT is the ‘ go-to’ treatment by the National Institute for Health and Care Excellence’s guidelines and American Psychological Association. Yet, Boyle and Johnstone (2014) suggest that CBT’s current paradigm for diagnosis (DSM-5) has failed and that psychologists should develop a new research focus on individual experiences and context. By addressing experiences, a diagnosis is not necessary as the client’s psychological distress is resolved. Reassurance, normalisation and explanation of problem behaviours and their lifestyle effects is a form of therapy itself (Ezzamel, et al 2015), one which does not require the distress of CBT or the label the DSM provides. This questions whether CBT is even needed, maybe what one needs is someone to listen, which may explain the effectiveness of the client-therapist relationship.

Happy canines shake their tails. Through observation, unhappy canines do not shake their tails. We deduct that if unhappy canines shook their tales then we predict they would become happy. Treatment research develops to teach unhappy canines to shake their tails. Once taught and they choose to carry out this action, their unhappiness will be cured (Dalal, 2018). This is precisely how maladaptive behaviours and psychological distress resolution is comprehended and implemented in society today. CBT and society view mental illness in terms of dichotomy: you are ‘ content’ and mentally stable or ‘ discontent’ and mentally unstable. Moreover, Seligman’s ethically ambiguous study (1967) gave electric shocks to dogs to show his concept of ‘ learnt helplessness’. He shocked the dogs continuously until they no longer attempted to escape the shocks and lay down on the ground whimpering. He anthropomorphised that there was a similarity between depression and learnt helplessness in humans, resulting in future negative schema of the self, the world and the future. This rigid behaviourist outlook CBT still holds, can explain why there are no further developments in implementing their ‘ holistic claims’. There is no exploration of external influences on psychological distress and behavioural interactions, instead, the problem is placed upon the individual refuting their ‘ holistic’ claim. The conflict within the rigid approach itself means that it is incomplete and needs further development.

CBT claims it reduces symptoms; amplifies the duration of improvement, the effects of symptom reduction as well as the number of people it helps. CBT holds a hyper-rationalist outlook, that only claims with evidence that are accurate and reasonable.  Hyper rationalists seek to control the cognitive and behavioural reactions we produce. If you are unable to do this you are classified as ‘ CBT resistant’ (Otto & Wisniewski, 2012) So in this regard, it could be seen that CBT has remained the best therapy in the field as it has manipulated the rules to its own advantage.

Waves

Behaviourism took the form of CBT’s first wave, the second wave hinged on cognition. It emphasised the control of thought and emphasised that one could transform their thoughts of negativity into ones of positivity. Beck (1976) identified three levels of cognition: Core beliefs, dysfunctional assumptions and negative automatic thoughts. He also constructed the negative triad: negative views on the self, the world and the future. In contrast, the third wave accepts internal angst and uses meditative techniques from philosophy (Hinduism, Buddhism) as coping mechanisms. For the qualification of these to count as CBT treatments, they need to be moral and directive, tested and manualized if efficacious. (Dalal. F, 2018) Some of these treatments include: Acceptance and Commitment Therapy, Functional Analytic Psychotherapy, Compassion focused therapy, metacognitive therapy and Dialectical Behavioural therapy. The philosophies initial function required a meditator to dissolve the self, whereas, within CBT, the focus is on self-reinforcement, which shows how these ancient techniques have been adapted for widespread uneducated human consumption.

Treatment

Before CBT diagnosis, the client is introduced to the Work and social adjustment scale (WSOS), General Anxiety Disorder Test (GAD 7) and the Patient Health Questionnaire (PHQ 9). Treatment within CBT focuses on the event, cognitive processing surrounding that event and the emotional effects of the event. The CBT approach presumes that two clients will respond to the same event in the same way; If they do not they are considered to have irrational cognition.

Holistic treatments are being replaced with phone calls and labelled as ‘ low-stress treatment’ and claim it is acceptable to clients. Richards and Whyte, (2011) discovered that therapy is prescribed in the form of phone calls and internet dialogue to cut costs. Yet, CBT claims to be person-centred, and holistic, moving away from the reductionist behaviourist approaches it was founded on. This means the actions being implemented for CBT contradict the approach claims. This further supports Ezzamel, et al’s (2015) suggestion that CBT may not be needed at all. These ‘ low-stress treatments’ create a de-personalised mutation of the client-therapist relationship and having a friend to listen may be just as effective.

Furthermore, Wiles et al., (2013) paper discovered that ‘ two out of ten’ people felt better after a CBT treatment process. This means that it may not work for the remaining eight. The two also only declared a 50% symptom reduction which means that the benefits may not last. Even this declaration is subjective, this finding comes from patient’s completion of the Clinical Outcomes in Routine Evaluation form (CORE), therefore the finding is subjective in the eyes of the researcher. CBT claims and presents itself as an inflated cure and one that lasts, and from this evidence, this is not the case.

Evidence-based treatments claims seem overpowering, but the research support is underwhelming. For example, DBT’s (Dialectical Behaviour therapy) treatment support consists of small sample groups of 20 in DBT and 22 in the TAU group. Furthermore, the 25 research paper authors were the researchers in the initial research team. This means that there was a singular experiment, but 25 research papers based on it. (Driessen, E., et al . 2010). This shows the conclusions that the treatment draws upon, are not reliable or valid. Furthermore, health agencies ignore negative research findings. For public use, only two concurring studies are needed (Davies, 2014). For example, NICE permitted ‘ Mindfulness-Based Cognitive Therapy’ due to a study replication of the same findings. Therefore, the central elements should be referred to as claims as they were created from corrupt concepts and support.

In conclusion, CBT research is continuous, and still has a long way to go before it can be officially classified as a ‘ gold standard of psychotherapy’. More attention needs to be placed on the individual and understanding of external influences rather than forcing a client to fit into a textbook case. Especially when the textbook is based on ambiguous concepts. In the attempt to cut costs, the holistic claim of CBT has disintegrated, and the economic pressure for results produced an uneducated venture into third wave philosophies to cope. CBT claims genuineness, empathy and understanding, yet what the client gets is the complete opposite. This approach needs to rename ‘ central elements’ into ‘ central claims’ until research support has a clear direction.

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