This article is part of our introductory series on cognitive-behaviour therapy.
CBT starts by a thorough assessment, followed by motivational enhancement, psycho-education and intervention.
Almost all clients present for psychotherapy as a result of some sort of an emotional or behavioural problem that may be affecting their ability to function in some way or another.
Emotional problems would include examples such as:
- depressed mood
- intense frustration
- shame or
Behavioural problems that either accompany such emotional problems or occur as primary presenting problems would include examples such as:
- substance abuse
- avoidant coping
- ineffective communication
- trichotillomania (hair pulling)/skin picking or
- defiance or oppositionality
Even when clients present with a practical problem that they feel they need help with (e.g. domestic abuse, indecision, dealing with difficult people), there is always some sort of emotional or behavioural hurdle that makes it difficult for them to implement a practical solution.
Any good CBT intervention is based on an initial assessment and understanding of the presenting problem. This is aimed at arriving at a diagnosis and conceptualisation upon which treatment is determined. Both psychotherapists and therapy-seeking clients would do well to be patient in ensuring that the primary concern is fully understood before embarking on any sort of intervention. Far too often treatment begins without a thorough conceptualisation of the problem. This would typically result from the following factors:
- an inadequate assessment process
- inadequate theoretical understanding of the presenting problem (on the part of the therapist)
- vital information being withheld by the client during the assessment phase, or
- impatience in starting with intervention on either the therapist or client’s behalf
Conceptualising the problem would typically entail the identification of the following factors that may be contributing toward the problem and its maintenance:
- predisposing or historical factors (relevant childhood experience, personality factors, core beliefs, genetic/familial history, pre-existing medical/psychiatric conditions)
- precipitating factors (recent stressors/events that may have contributed toward the development of the current emotional or behavioural problem)
- perpetuating factors (environmental factors/behaviours/beliefs) that are responsible for the maintenance of the problem.
- protective factors (beliefs, behaviours, strengths and social support) that assist the client in dealing with this problem.
Treatment should thus be based on a conceptualisation of the problem based on the above-mentioned factors. Treatment strategies essentially target those factors (often maintenance or perpetuating factors) that, if altered, would result in remission of the most pressing emotional and behavioural symptoms.
In CBT, certain specific beliefs and behaviours are typically seen as central to the maintenance of emotional and behavioural problems, and a variety of strategies and techniques are used in altering such beliefs or perceptions. Altering certain behavioural reactions is often also of central importance. The primary difference between CBT and other psychotherapy approaches is that CBT conceptualises psychological disturbance in this way, and sees faulty or dysfunctional thinking as central to such disturbance.
One of the primary criticisms that CBT has of other therapeutic approaches is that non-CBT approaches typically use models for understanding psychological problems that are based on abstract and unmeasurable concepts and phenomena upon which treatment strategies are based, for which there is often little empirical (scientific) support. Beliefs and behaviours are measurable concepts which can be altered through intervention. There is now ample evidence from research to suggest that if one identifies and targets the correct beliefs and or behavioural patterns associated with such emotional or behavioural disturbance, then intervention is likely to be effective and psychological disturbance likely to diminish.
The assessment of someone who presents with panic disorder would, for instance, focus greatly on identifying the catastrophic misappraisals associated with what they fear may result from their panic, for example “I could have a heart attack” or “I could lose control of myself or go crazy”.
It would also seek to identify the escape or avoidance behaviours accompanying the individual’s anxiety, as well as the use of ‘safety’ behaviours aimed at preventing anxiety or panic. Such escape or avoidance, or the use of safety behaviours are typically targeted during intervention as a means of disproving one’s inaccurate predictions about the threat of panic.
The assessment of someone who presents with depression would often focus initially on the most recent and pressing set of circumstances that may have triggered the depressive episode together with the thoughts or beliefs that the individual has about the meaning of these events. Assessment would be aimed at developing a cognitive conceptualisation of how these factors interact together. Therapists would also want to assess for avoidant behaviour or withdrawal, which is often based on lethargy and a sense of helplessness and hopelessness. Such behavioural inactivation is considered as a perpetuating factor for depressed mood as it reduces the opportunity for perceived accomplishment or pleasure.
Motivational enhancement and psycho-education
With certain emotional (primarily anger) and behavioural problems (procrastination, substance abuse and aggression), time may initially be required for motivational enhancement as clients with such presenting problems are often not sufficiently motivated, prepared or committed to begin immediately with active intervention.
Clients with anger problems often blame their anger on the world as oppose to their reactions to it; and individuals with substance abuse or addiction problems often initially present as a result of the pressure of loved ones. Individuals with mood and anxiety disorder symptoms typically need less motivational enhancement as the discomfort of their symptoms is already sufficient to enhance motivation for intervention. Such individuals may, however, require some assistance in preparing for the often difficult but worthwhile challenges that effective treatment will require. For instance, those suffering with anxiety symptoms are often encouraged to ‘face their fears’ in very specific and structured ways for the sake of disproving them. Individuals with panic disorder are often prepared to get used to the physical sensations that normally trigger panic for the sake of learning that these do not result in any of the catastrophic outcomes that the individual is afraid of.
Those with OCD may be encouraged (as a part of prolonged exposure and response prevention) to purposely think the thoughts that they would normally try to suppress or discard. Such intervention strategies are, however, often difficult for clients to engage with, and a fair degree of motivational enhancement is often necessary for clients to appreciate the long-term benefits thereof.
Psycho-education involves the explanation of the therapist’s conceptualisation of the problem and an explanation of which factors would need to be targeted throughout intervention in order for treatment to be effective and remission to occur. This is an important stage in the treatment process as the requirements of treatment become clear and this assists clients to prepare for intervention, in addition to providing the platform for the client to discuss his/her concerns with the therapist who can then assist in allaying fears or further enhancing motivational readiness.
Subsequent to diagnosis, conceptualisation and the development of a treatment strategy, therapists and their clients should be in a position to discuss the expected length of intervention and exactly what it would entail. Referral for medication to a general practitioner or psychiatrist may be indicated depending on the nature and severity of the presenting problem.
Active intervention is usually focused on reducing distressing emotional states and/or self-defeating behaviour. Most sessions would begin with an assessment of the primary clinical problem, be it mood or behaviour, from the preceding week. This would typically be followed by a discussion of the therapeutic homework assignment that may have been set for the preceding week. The session is then governed by an agenda set collaboratively by the therapist and client.
The majority of the active work throughout the session typically involves a great deal of collaborative and interactive discussion between the therapist and client that is aimed at identifying specific beliefs perceived to underlie the primary clinical problem.
Once identified, these beliefs are usually evaluated for their accuracy and helpfulness or inaccuracy and unhelpfulness. More helpful and functional beliefs are then identified and discussed with respect to their potential in alleviating emotional distress and/or reducing destructive behaviour.
Therapeutic homework assignments are often aimed at testing out certain inaccurate beliefs or practising the implementation of new functional ways of thinking. Good CBT therapists will not only spend time with their clients developing new, helpful ways of thinking, but will also set specific tasks aimed at helping clients implement such alternative philosophies.
CBT is thus as much a “doing therapy” as what it is a “talking therapy”. The reality is that “talking” often results in little progress if it isn’t simultaneously accompanied by an alternative way of “doing”. Therapeutic sessions may also involve a considerable degree of discussion about adopting different behavioural reactions that may assist in reducing depressed mood, anxiety, hair pulling (in trichotillomania), cravings for illicit substances or managing perpetuating factors in insomnia. Homework assignments may thus also involve the adoption of alternative behavioural reactions.
Written by Bradley Drake and Jaco Rossouw, Centre for Cognitive-Behaviour Therapy, Cape Town, South-Africa. For further details visit: www.cognitive-behaviour-therapy.co.za. (September 2011)
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