This article aims to inform psychologists about advances in cognitive behaviour therapy (CBT). Multiple surveys of the psychology training programs in Australia have shown that CBT is the foremost therapeutic model in the education of provisionally registered psychologists. CBT (and CBT components) are the main Medicare-approved focused psychological strategies under the Better Access Initiative.
Before outlining what CBT looks like in the 2020s, we acknowledge some of the controversies surrounding diagnosis, and trace how the evolution in psychological therapies has lead us to the present concept of a ‘family of CBTs.’ Acceptance and commitment therapy (ACT), dialectical behaviour therapy (DBT), mindfulness-based cognitive therapy (MBCT) and schema therapy are among the therapies that are now part of the family of CBTs. This evolved concept of CBT reflects advances in the clinical psychological science underpinning therapies, with ever more refined and efficient approaches being tested for a range of presenting problems and presentations. The discussion below extends into a short case study, and collectively this is intended as an introduction to the Advanced CBT elearning course that has been developed by the Australian Psychological Society.
Diagnosis: Pros and cons
The editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM) produced by the American Psychiatric Association, and other major classification systems such as the International Classification of Diseases (ICD), have led to important clarifications for clinical practice. Diagnosis provides a common language for our work and benefits work in inter-professional contexts and therefore can be useful for clients. Often clients take a deep sigh of relief to know that the distress they experience has a name, a prevalence and a specific treatment with an evidence base.
CBT was initially formulated as a treatment of depression, and it was not until the 1980s that it was modified as a model to assist with panic and other anxiety disorders. Yet while the techniques varied in the application, the basic undergirding theory remained the same. In 2021, CBT remains a first-line intervention for acute phase distress among a number of common disorders.
Modern funding organisations, such as the U.S. National Institute of Mental Health view mental health problems as ‘disorders’ and fund research that targets ‘brain circuits.’ DSM-5 continues this framework through its attempt to identify genetic markers, neural substrates and biomarkers. However, at the time of writing, there is limited evidence for these biological mechanisms in differentiating disorders to predicting treatment outcomes.
The categories of current diagnostic systems also fall short of capturing the diversity of clients’ experience. Many disorders have arbitrarily defined numbers of symptom clusters, and the duration for which symptoms need to have been present remains controversial. Many client presentations have comorbidities and overlapping symptoms with health conditions.
Indeed, the assumption that all instances of clinically significant psychological distress represent ‘an illness’ that requires a ‘cure, or treatment’ does not always rest comfortably with psychologists working with clients in community settings.
There are also many perspectives and worldviews that are not captured in the DSM. While we may often work with individuals in psychological therapy, every family context carries beliefs and concepts of health and wellness, both overtly and subtly.
Many cultures have beliefs about emotions, and how to express them, or not. For example, some traditional cultural practices include expectations for family members to outwardly show intense grief at times of loss, whereas elsewhere a display of emotion is taken as a sign of immaturity and unchecked emotion is expected to be associated with shame and embarrassment. Further still, some cultural values extend to expectations for logical thinking, precise communication, whereas elsewhere circular discussion is expected and is seen as a gentle and non-combative, respectful approach. Persistent worry about children and elders is also expected in some cultures.
In Australia, the traditional custodians of our land hold holistic perceptions of health and wellness that have been influential and can be usefully adopted when working with clients. The concepts of ‘connection to community’ and wellbeing as being a reflection of connection to family, culture, and context are often useful.
Suffice to say that diagnosis continues to have an important role, but it has real limitations as a roadmap for psychological intervention.
A family of CBTs
Even though a growing practice emphasis in CBT has been documented in recent decades, few psychologists identify that they adopt just one therapy approach or select techniques from a single model.
In practice surveys, psychologists report that they combine multiple theoretical models in the provision of focused psychological therapies, and the same findings have been obtained when psychologists have been surveyed in Australia and other countries.
Terminology varies, but whether we consider this pluralism as reflective of ‘technical eclecticism’ or ‘theoretical integration’, most of the evidence for psychological therapies comes from studies aimed to treat single-disorders, and only a few consider combination treatments leaving psychologists feeling a significant gap between the science and practice of psychological therapies.
Those of us trained in the 1970s–90s witnessed a surge in therapies; from behaviour therapy, to client-centred therapy, gestalt and experiential therapy, cognitive behaviour therapy, through until third-wave therapies such as mindfulness and acceptance-based approaches, which have each developed a sound evidence-base.
One could ask if CBT is not just the therapy developed by Aaron T. Beck, then what is it exactly? All CBTs share an emphasis on changing a client’s relationship with their thoughts. Some models focus on identifying and distancing; others on re-appraisal of those thoughts, assumptions and beliefs.
But what about behaviour change? We could say that all CBTs also involve a focus on enhancing interpersonal effectiveness, and changing relationships with context/environment, attention (and other processes of cognition).
Problematic cognitions can be understood as operating under similar conditions to observable behaviours, so CBTs can be defined as therapy models resting on an integration of behaviour and cognitive theories. Therefore, we now refer to a family of CBTs, which includes therapy models that centre on behaviour change processes, such as ACT and DBT, as well as those focusing on cognitive change such as MBCT and schema therapy.
Those therapies, or therapy protocols, that attempt to remove one or more ‘disorders’ are still entrenched within a medical model, whereby mental health is deemed a ‘disease’ or at least to have ‘disease entities’. Modern CBT targets the underlying processes that determine psychopathology, but not in a rigid, prescriptive or manualised form.
In 2021, we are less concerned about the ‘brands of therapy’ or ‘manuals’, formulating client presentations in terms of disorders, or rigidly adhering to a medical model. The days of efforts to pioneer a ‘new’ therapy are numbered; advances in clinical science now focus on evidence-based refinements and focus on the actual tailoring of what works, for whom, under which relational contexts.
Modern CBT
Emerging conceptualisations of CBT target common etiological factors, across disorders. For example, by targeting emotion identification and coping, a client may be better equipped to manage anxiety and reduce their symptoms of depression.
By focusing on etiological processes, we can identify targets for therapy with the expressed purpose of helping clients to learn skills in those areas:
- Emotion regulation skills, for example, are central to the aetiology of depression, but at the same time re-appraisal and repetitive thinking are interconnected processes;
- There are also interconnections between interpretational and other cognitive processes. Attention and memory interact with biases in appraisal, associations and interpretations, for example in many anxiety presentations, supporting clients in their anticipatory thought process, selective attention to information supporting their assumptions and deeper beliefs, and reconsidering post-event and other unhelpful repetitive thought processes;
- Mental imagery is widely present in emotional disorders, and can have a particularly strong effect on emotions, cognition and behaviour. Techniques such as imagery re-scripting that directly target images, and traditional CBT cognitive processing techniques using images as the expression of the thought are indicated.
|
This modern concept of CBT frees us to consider evidence-based techniques that are useful to the client, without being concerned about from which particular therapy they originate. This means we are less concerned about removing ‘illness’ or ‘disorder’ and more concerned about helping clients learn adaptive skills that are broadly applicable. This approach is more suited to the reality of clinical work as an innately relational and humanistic endeavour. Pre-formulated therapy sessions have their place in-group and technology augmented therapy, but for those of us privileged to work with clients one-on-one, we know that two sessions are rarely the same.
Case example
‘Elon’ was a 27-year-old man who presented with weekly panic attacks and symptoms of depression. Due to the specific array of his symptom profile, Elon did not meet DSM criteria either for panic disorder or depression. However, he said that he “felt” as though he was at real risk of panic attacks in triggering situations (e.g., when drinking too much coffee, during exercise) and he was generally functioning at work despite very low motivation. Elon’s goals were to reduce panic attacks, enhance motivation and his ultimate therapeutic goal was to be panic-free. He considered that his low motivation and other signs of depression were secondary to his panic symptoms, as his panic predated low motivation and he explained “the panic is getting me down, and it’s unusual for me to be feeling low motivation.”
In Elon’s case, his goals were not atypical for a client presenting with a primary concern of persistent panic primary to low mood. However, his therapist saw a need to liaise with his referring GP, because there was definite comorbidity and DSM criteria were not clearly met, and these factors might have been important for both the GP Mental Health Care Plan and also as considerations when his GP was reviewing his concurrent pharmacotherapy. Open and clear communication, and good relationships with referrers are very much in the best interests of the clients we serve.
In collaborating upon an initial treatment plan for Elon, the therapist found it was useful to extract from the evidence-based CBT model for panic disorder, whereby a central emphasis is placed on the catastrophic misinterpretations of bodily sensations. To support Elon in re-evaluating the meaning of his physiology, his therapist adopted interoceptive exposure with cognitive re-appraisal.
To support Elon in developing solid skills in mood management, his therapist drew from the evidence-based CBT model for depression, whereby the initial phase of treatment is devoted towards identification of emotions, and scheduling of activity and pleasant events (i.e., activation). Elon responded very well. Partly due to his engagement in between-session tasks, he was panic free at session 3 and his motivation had returned by session 6. It was notable that Elon was highly engaged in interoceptive exposure; over-breathing produced sensations that were similar to his naturally occurring anxiety (rated as 7/10 similar) and he developed a sense of control and accomplishment from noticing that more over-breathing was necessary in order to produce the same sensations. Elon was then able to return to his double espresso each morning and was able to manage anxiety across situations and remained panic-free.
Elon’s therapist flexibly applied evidence-based CBT interventions, but linked them to the etiological processes throughout all sessions. Elon’s therapist revisited the rationale for misinterpretation of physiology repeatedly, and couched interoceptive exposure as a recalibration of the communication between cortex and limbic system. Here, the treatment process was cognitive reappraisal.
Similarly, Elon was engaged with increasing physical activity increasing social contacts, and scheduling activities that brought him a sense of enjoyment and fulfilment. Again, the rationale for generating motivation through action was helpful for Elon. Here, the process was activation, which rested upon therapy time spent in identifying and differentiating emotions.
The case of Elon illustrates that flexible application of CBT includes an entirely personalised tailored selection and application of techniques. Elon’s symptom profile did not fit DSM, and his therapist did not follow a manualised CBT protocol or predetermined set of interventions when supporting him through his symptoms of panic and depression.
As time went on, Elon felt comfortable disclosing that had taken an interest in meditation and so the discussions in-session moved to a development of “a new relationship with thought process” that focused on distancing and acceptance as a final treatment process. The work with Elon was clearly grounded on evidence-based CBT interventions and also tailored through a focus was on those etiological factors of psychopathology. Elon understood the rationale very clearly when the therapist labelled the pivotal processes through the work. Elon’s long-term outcome was very positive.
Of course, all of Elon’s therapy existed in the context of a professional client-therapist relationship, and that relationship is the catalyst by which a treatment plan such as the one outlined is useful.
Advanced CBT elearning course
With input from the esteemed leaders in Australian psychology comprising the Expert Reference Group, the APS has developed a new Advanced CBT elearning course.
Importantly, the evolution we have witnessed in CBT has included the development of theoretically integrative and flexible case formulation approaches, incorporating attachment styles, schema, values and to the delineation of specific elements of the therapeutic relationship, such as collaborative empiricism and Socratic dialogue that rest upon a foundation of sound counselling skills. These are the focus of the APS Advanced CBT elearning course (bit.ly/3e562wt).
This article outlined some of the ways CBT has evolved from a disorder-specific and manualised approach to a flexible modality. It retains efficiency and adaptability through this evolution and enables the clinician to work with clients to develop individually tailored treatment plans.
The aim is to inspire and generate enthusiasm for the possibilities within an evolved concept of CBT. Together with the new APS course, the intention is to enrich the focused psychological strategies made available by APS members for the benefit of the Australian community.
Contact the first author: www.nikolaoskazantzis.com