Unit 5 Cognitive Behaviour Therapy

In this essay I have attempted to show a personal understanding of

Beck's theory of cognitive behaviour therapy with reference to the

course materials and suggested reading, and to discuss its application

with regard to people diagnosed with a learning disability.

In order to show an understanding of the benefits and the drawbacks

of Beck’s theory of cognitive therapy and its use in the treatment of

emotional disorders, I have kept a diary of incidents over the course of

one week which I have presented in the form of a chart (fig 1). I have

avoided discussion of sensitive personal issues and have concentrated

on those incidents that may be explained using Beck’s theory.

Beck’s Cognitive Therapy

Beck’s theory of cognitive behaviour therapy suggests that existing

schools of thought such as neuropsychiatry, psychoanalysis and

behaviouralism are all based on the idea that the patient has no

control over his condition, or his emotional state,

“Despite the striking differences among these dominant schools, they

share one basic assumption: The emotionally disturbed person is

victimized by concealed forces over which he has no control”

(Beck 1976)

The intention of Cognitive Behaviour Therapy is to focus on styles of

thinking that affect the subject now, rather than other forms of taking

therapy which tend to focus on past events. It combines cognitive

techniques designed to modify negative thoughts and beliefs, and

behaviour therapy, which focuses on your response to those thoughts.

Styles of thinking can become habitual to the extent that we begin to

anticipate how we will react given a particular situation or set of

circumstances.

Because these responses are self imposed, Beck avers that with proper

guidance the individual may learn to recognise (through what he calls

metacognition) that thinking need not be automatic, but can in fact be

easily modified. This involves consideration of alternative responses,

examination of evidence to support the automatic response and the

contemplation of a ‘worst case scenario’.

Cognitive therapy suggests that events in themselves are not to blame

for negative thinking, but the emotional response or significance that

we attach to those events.

During a course of cognitive therapy the subject will be asked to focus

on and analyse their own responses to current or recent events. They

may be required to keep a diary of events and responses to situations

that cause anxiety. Because of this need for personal commitment and

involvement outside the therapy session, this type of treatment does

not work for everybody.

Traditional psychotherapy involves talking about past events in a free

and open way but does not require commitment from the subject in

the same way. Similarly, subjects with complex mental health issues

may not find this type of therapy successful.

CBT tends to be focused on specific problems and the alleviation of

those problems. It is highly structured and practical in its approach.

Beck stresses that

“Symptomatic change should not be mistaken for a fundamental

change of attitude in the subject “

(Beck (1976).

In other words, a specific symptom or problem may be alleviated

through cognitive modification, but this will not have long term

benefits if the underlying thought process is not modified.

"The underlying attitude, however, is the component that needs to be

changed ultimately if the totality of the depression is to be influenced.

Thus, the goal is cognitive modification." (p. 268)

(Beck ibid.)

When compared with other therapeutic techniques, there seems to be

little to choose between CBT and others. A study undertaken in

Germany in 2001 showed the effects of short term psychodynamic

psychotherapy on patients suffering from depression compared with

cognitive behaviour therapy . In 97% of the comparisons it was

regarded that:

“STPP and CBT/BT did not differ significantly with regard to the

patients that were judged as remitted or improved.” (Leichsenring

2001)

More recently, this year a study of the comparative efficacy of

behavioural couples therapy (BCT) carried out in Holland showed that,

when applied to couples suffering from the effects of alcohol addiction,

there was little to differentiate between the effects of treatment via

BCT and CBT:

“ Stand-alone BCT is as effective as CBT in terms of reduced drinking

and to some extent more effective in terms of enhancing relationship

satisfaction. However, BCT is a more costly intervention, given that

treatment sessions lasted almost twice as long as individual CBT

sessions.”

(Vedel et al 2008)

This seems to indicate that CBT is at least as effective as other

approaches in the treatment of conditions such as depression and

anxiety and in treating addictions.

The Cognitive Triad

Beck refers to the circumstances that lead to depressive thinking as

the "cognitive triad." (Beck, 1970) The cognitive triad can be used to

explain how those who are depressed view themselves, their world,

and their future.

An event will trigger an emotional response in a given individual. This

response will vary from person to person. a depressed person may feel

that any event which affects him will have a negative consequence.

Firstly, the depressed person thinks that there is something wrong with

him or her that makes happiness impossible. For example, a depressed

person thinks, "I am a loser" or "I am stupid."

Secondly, because of this perceived personal inadequacy the

depressed person notices negative circumstances but ignores positive,

fortunate circumstances.

Thirdly, because of the belief that he or she is inadequate, and his or

her tendency to only notice negative experiences, the future is viewed

as certain to be gloomy, dismal, and painful.

For example, the depressed person may frequently receive positive

feedback concerning his or her performance at work. A customer or

colleague -- who is obviously in a bad mood -- complains. The

depressed worker can only think about the complaint and sees it as
confirming what a poor worker he or she is. The many positive

comments that have been made are not even remembered.

According to Beck and Emery (1985),

"Anxious patients in the simplest terms believe that something bad is

going to happen that they won’t be able to deal with."

It is the fear that leads to irrational and instinctive reactions, designed

to avoid the expected conflict and protect the individual.

They advanced three basic strategic questions detailing how a process

of cognitive restructuring could be achieved in this case.

1. What is the evidence supporting the conclusion currently held by

the client?

2. What is another way of looking at the same situation but

reaching another conclusion?

3. What will happen if, indeed, the current conclusion/opinion is

correct?

Example C from the chart below describes a typical thought process of

mine.

I am awake early; my first thought is that I have woken because I am

worried about the essay I have yet to complete. It does not occur to

me that I may have been woken by the cat or by a car starting outside.

This assumption leads to the notion that I will not be able to be happy,

or feel relaxed until this piece of work is complete. This notion then

begins to affect my state of mind, to the point that when a colleague or

friend asks me “how are you?” I immediately focus on the one thing

that is causing me to feel negative and explain that I am not feeling

good because of this unfinished task.

Taking the example above, it could be said that I am feeling negative

about myself, because I believe I am not sufficiently skilled to complete

the task at hand; this makes me feel negative about the world, in that I

cease to enjoy the process of learning and am an unfit student; and

thus negative about the future, I am unlikely to get a pass mark, and

will probably fail the course. The problem here is that some of these

events will happen, not because I am being negative, but because they

may actually reflect the situation as it is. I can begin to see this as part

of a wider, more fundamental problem with my thinking. I dread the

idea of failing and consequently I hate getting things wrong.

It is clear that my reactions are automatic to a marked degree, and it is

only when considering my reactions and behaviour at a distance that I

am able to realize what I should have said and done.

Diary
I chose a week at random during which to record incidents where I felt

mild negative reactions to specific events. As suggested I have

recorded these incidents on a chart (Fig 1).

Below I have tried to evaluate each incident in turn as it relates to the

theory under discussion.

Example A

Situation

I am attending a mandatory training session at work; all of the other

students are younger support workers, and as such, junior to me in

terms of age and experience. I am certainly the most experienced

person in the group, and should be able to answer the majority of the

questions. Next to me is a female staff member, who has joined the

company only recently. She has little experience of this particular field,

yet she consistently fields answers to the tutor's questions. I feel

myself getting annoyed by what I see as her attention seeking

behaviour. She refuses to use a chair and sits on the floor; she takes

her shoes off; she is happy to blurt out answers despite her evident

lack of knowledge. She behaves as if she knows people well, despite

having never met them before. Later, when we break for lunch, I end

up seated next to her, and feel my irritation increasing as she talks

about herself. She also begins to discuss residents at the care home

where she is working, people with whom I used to work. I know she is

not observing confidentiality, and is using proper names and

discussing their behaviour. She is later reprimanded for this by our

tutoy.

Evaluation

I do realise that she is unreasonably irritating me, and this in itself

begins to annoy me. I feel the urge to put her straight on a number of

issues, but feel disinclined to confront her openly. Instead I make a few

vague remarks, in a way that is as ineffectual as it is pointless. My

criticisms are far too subtle to get through. In the context of this

training session, we are all students and have an equal right and

opportunity to contribute.

This could be characterized as my jumping to conclusions about the

individual concerned, although what seems more significant in this

situation is my concern about my own position within the group. Why

do people like this bother me so much? This personalisation leads to

problems at times as others will not be judging the situation by the

same criteria, and I will assume that others are thinking what I am

thinking.

Example B

Situation

Thursday
I am on the phone to my credit card company, in answer to a letter I

have received about non payment of bills. This is the third time I have

addressed this issue and I begin the phone call in an already

heightened state of anticipation. I have my explanation to hand, as

well as the information I

have gathered during my previous encounters. There has been an

administrative error which, although being corrected over the phone

has not yet been reflected as a payment.

The reason I am so tense is that my wife has already cast doubt upon

my ability to handle finances, and sees this as just another mistake on

my part.

I am annoyed with her because I feel she has a valid point about my

responsibility where domestic finances are concerned, although to be

fair in this particular case I have met my responsibilities.

It has been established from past experience that I am not very good

at this. Because of this, I avoid dealing with money wherever possible.

And yet here I am making a considerable meal of what should be a

very simple phone call, because I do not only have to please the

company and my bank, but also have to please my wife. Here is an

example of over generalization, my assumption that call center staff

are going to be unhelpful, officious and ill informed. I forget that I once

worked in a box office and all day long had to field calls from
disgruntled cinemagoers. This knowledge has no effect on my attitude

at the time. I am forgetting that call center personnel are provided with

protocols they must follow in order to do their job efficiently, and in

this case, protect the confidentiality of their customers. There is a

certain element of personalization here as well, as I have done all I can

to reach a satisfactory resolution of this issue, but continue to blame

myself and accept blame from others for the continuing problem.

Example C

Situation

Friday morning

I awake at 5.30. My alarm is due to go off in one hour. Hardly enough

time to go back to sleep, even if I wasn't worrying about this very

essay you are reading now. I should be putting aside time to read the

course materials and then, having made some notes, start to put

together my ideas. I haven't done a stroke. I have plenty of time. I

believe I have the ability to write succinctly, but I am convinced I will

not be able to make a good job of meeting the requirements of the

task. So I avoid it, make excuses and do other things, then I remember

what I should be doing and feel anxious. Faced with the reality of

having to work and have that work judged, I consider how it would be

if I just didn't do it. What's the worst that could happen?

In this situation I would feel as if I had failed, and believe that everyone

else would feel the same. I would have to live with the knowledge that

if I had only sacrificed some of my leisure time, and got down to work I

could have succeeded. This could be described as a form of absolutism

– if we assume that I want to complete the set task and make a good

job of it, then assuming that I will fail must be based on previous

experience. The evidence is that when I concentrate and apply myself

then I am able to complete an essay successfully; when I do not then

my work suffers. The worst that could happen is that I would be forced

to recognize my own shortcomings, and for me this seems to be the

worst thing of all.

Example D

Situation

Saturday night

My wife and I throw a party for her birthday. I actually have very little

involvement, as she invites everyone and makes arrangements. I have

to work in the morning and so I begin to feel a little uncomfortable

about going to bed, as I don’t think I will be able to sleep with all the

noise. I recall similar situations in the past when I have become angry

and upset by this kind of situation. Everybody is, however, extremely

understanding and I am left in peace.

I can begin to see a pattern emerging, with which I confess I am quite

uncomfortable. There is a common element of personalisation. I am

only concerned about how this evening will affect me; I appear to have

forgotten the fact that it is my wife’s birthday, and that the guests

have been invited to enjoy themselves and our hospitality. I am unable

to relax and participate and look to blame my

discomfort on the behaviour of others. To make matters worse, the

next day when this is pointed out to me I become angry and defensive;

it seems I wish to reserve the right to be right, even when I know I am

wrong.

Example E

Situation

My wife mentions the events of Saturday night and offers her opinion

that I could have been more sociable. I feel aggrieved and become

annoyed with her

Again, personalizing the issue, I seem to require that others should see

my point of view: I had to work the next day, I needed an early night

etc. Realistically, the worst outcome would have been a sore head and

feeling tired the next day. I have frequently chosen to go out and enjoy

myself on weeknights and have suffered no ill effects the next day; the

difference seems to be that I have chosen to do this, and I stand to

benefit from it in some way, rather than having to put aside my

personal needs in order to benefit another. My wife is of course right

about my motivation and it seems it is this feeling of transparency that

I am so uncomfortable with. I want to feel that I can behave badly, and

pretend that I am not.

Thinking Styles

A theme that runs through this exercise is my tendency to focus on

how others’ behaviour affects me, and not how mine is likely to affect

them. This self directed thinking is bound to create situations where

the satisfaction of the needs of others becomes secondary to my own.

The discovery that those around me do not share my immediate

concerns seems to come as a shock, and this leads to negative

thoughts about myself in any social situation. What would seem to help

here would be to develop a response that focuses on putting the needs

of others first as a matter of course, in the way I am required to do in

my capacity as a carer. It is perhaps significant that the situations I

have described, with the exception of the training session, have all

taken place outside of work. My workplace is a highly structured

environment with clear rules and procedures, and where my

responsibilities are clearly circumscribed. There is a tendency to resort

to “all or nothing” thinking at times which allows me to withdraw and

accept failure as an option, rather than setting a realistic goal and

setting out to achieve it. Sanders (1997) describes and expands upon

Beck’s idea of cognitive distortions, which lead to an individual’s

thinking becoming thematic.

“These themes become elaborated and maintained by the day-to-day

‘dripping tap’ effect of the client’s ‘negative automatic thoughts’”

Hence an individual’s negative thoughts become automatic and serve

to reinforce the underlying ‘theme’, in my case, what Beck terms

crystal ball gazing, where I tend to predict a negative outcome despite

evidence to the contrary.

Cognitive Behaviour Therapy for people with a learning

disability

Applying this kind of therapy to someone with a learning disability

raises numerous issues involving consent, effective communication

and confidentiality. Dagnan and Chadwick (1997) describe a model

(suggested by Trower, Casey and Dryden 1988) that enables a person

with a learning difficulty to engage in a simple form of cognitive

therapy, using a framework of Antecedent, Belief and Consequence

(ABC). In this model the subject is not required to make judgements or

evaluations of events or the emotions stirred by those events. The

event (A) is followed by a consequence (C) that is dependent upon the

beliefs or inferences (B) held by the individual, rather than the

antecedent itself. This simplified process does not delve as deeply as

cognitive therapy but nonetheless involves the subject in a process of

cognition, and regarding his reactions in direct relation to his own

beliefs.

They quote Beck's demonstration that

"inferences in the form of anticipations and recollections tend to be

distorted and biased because of the influence of mood"

Dagnan & Chadwick 1997

An assessment of 29 people enabled them to establish that at least

some people with learning disabilities are able to distinguish between

events, beliefs and the emotions that follow as a consequence, and

that such people could benefit from this type of therapy.

This suggests that an adapted form of cognitive therapy can be useful

in dealing with depression and anxiety for those with a learning

disability.

Lindsay, Neilson and Lawrenson (1997) describe two cases in detail

where cognitive therapy has been shown to be effective. One case

involved a course of treatment over the period of a year, designed to

alleviate the extreme anxiety displayed by the subject, who was

unable to leave his flat due to his fear of being attacked, and who also

became highly anxious when indoors. The resultant anxiety led him to

set fire to his flat. He was found to be having several automatic

thoughts which led him to misconstrue his situation and exaggerate his

feelings of loneliness and fear. A process of daily assessment using

histograms was used to work on these negative automatic thoughts.

The therapy enabled him to replace these negative thoughts with

simple adaptive thoughts. Another subject was encouraged to keep a

diary and to view slides which were used to monitor his reaction to

panic attacks when having to work around women. In both cases the

Beck Anxiety Inventory and Beck Depressive Inventory scores showed

a marked improvement.

Problems

The difficulties inherent in adapting cognitive interventions for people

with learning disabilities are discussed by Jones et al(1997)

They state that problems with language, poor memory and information

processing can and have been overcome, but there remain problems

with motivation, self esteem and social cognition. Motivation suffers as

a result of dependency upon others which is often characteristic of

individuals who have lived most of their lives in an institutionalised

environment. This dependency leads to feelings of helplessness and an

unwillingness to try (Zigler and Hodapp, quoted in Jones et al) and

coupled with a desire to please others at the expense of themselves

results in low self motivation. The failures produced by this lack of

motivation contribute to feelings of low self esteem.

Beck’s theory seems to play down the influence of environmental

factors such as hormonal imbalance, illness, tiredness and boredom as

well as the irrational and unreasonable behaviour of others. Certainly

we can correct our negative thoughts in situations such as these, or at

least recognize that things will probably improve after a good night’s

sleep, but these are not stimulated purely by our negative thinking,

they are to a greater or lesser extent, beyond our control.

Beck refers to “common sense” as a principle, and this certainly has

value when we are evaluating our responses to events.

Andrews (1996) shows that the effectiveness of cognitive therapy can

be measured favourably against other psychological treatments, such

as counseling and psychotherapy.

The OED tells me that counselling is “help or advice given formally”,

my own lay definition would be a process of communicating between

two individuals, where one individual is charged with the responsibility

of encouraging the other to talk openly about him or herself without

fear of being judged or criticized. One person cannot tell another how

to think or feel, nor do they have the right in a situation like this to give

an opinion as to whether a particular thought or way of thinking is right

or wrong.

the British Association for Counselling is quite clear in it’s definition

that,

“It does not involve giving advice or directing a client to take a

particular course of action”

(BAC 1979)

The relationship that develops between the counselor and the

individual seeking treatment is a complex and influential factor in the

success of the intervention One of the major drawbacks of Beck’s

theory is the assumption that there are right and wrong ways of

thinking, and that this assumption may inform the relationship

between the counsellor and the individual seeking advice.

Conclusion

Beck suggests that negative thoughts can be seen as part of a

cognitive triad; these thoughts can be about oneself, the world around

us or our view of the future.

These negative or erroneous thinking styles do not necessarily need an

event or interaction in order to become effective; they can be

stimulated by your own emotions, thoughts and recollections.

The principle of cognitive behaviour therapy is an attractive one to the

person seeking treatment. The suggestion that we as individuals can

take control of our thought processes is an empowering idea. A

counselor should be able to steer the individual towards a more

balanced and rational thought process without suggesting that the

subject is ‘wrong’ in his or her thinking, but merely the victim of a self

imposed negative viewpoint. It is possible to apply this technique to

persons with a limited use of language or poor information skills, such

as may be found amongst those labelled as learning disabled. It

demands an adapted form of questioning and careful screening firstly

to identify those who may be suitable candidates, but those who meet
the criteria have been shown to be capable of modifying their cognitive

processes and achieving some resolution.

References

Andrews, G. (1996). Talk that works: The rise of cognitive behaviour

therapy. British Medical Journal, 3(13), 1501 – 1502

British Association for Counselling. (1999). What is Counselling?

Training and Careers in Counselling. Rugby, Warks: British Association

for Counselling. (Extract)

Beck, A. (1970). Depression: Causes and Treatment. Philadelphia:

University of Pennsylvania Press.

Beck, A. (1976). Cognitive Therapy and the Emotional Disorders. New

York: International University Press

Beck, A.T., & Emery, G. (1985). Anxiety disorders and phobias: A

cognitive perspective. New York: Basic Books

Dagnan, D. and Chadwick, P.(1997) Cognitive -behaviour therapy for

people with learning disabilities: assessment and intervention. In B. S.

Kroese, D. Dagnan and K. Loumidis (eds) Cognitive-Behaviour Therapy

for People with Learning Disabilities. New York: Routledge.

Jones, Robert S.P., Miller, B, Williams, H, Goldthorp, J. (1997)

Theoretical and practical issues in cognitive-behavioural approaches

for people with learning disabilities: A radical behavioural perspective.

In B. S. Kroese, D. Dagnan and K. Loumidis (eds) Cognitive-Behaviour

Therapy for People with Learning Disabilities. New York: Routledge.

Leichsenring, F. (2001) Comparative effects of short term

psychodynamic psychotherapy and cognitive-behavioral therapy in

depression: A meta-analytic approach. Clinical Psychology Review Vol

21, issue 3, 401-419

Lindsay, W., Neilson, C. and Lawrenson, H.(1997) Cognitive behaviour

therapy for anxiety in people with learning disabilities. In B. S. Kroese,

D. Dagnan and K. Loumidis (eds) Cognitive-Behaviour Therapy for

People with Learning Disabilities. New York: Routledge.

Sanders, W.F. (1997) Cognitive Therapy: transforming the image.

London. Sage.

Vedel, E., Emmelkamp, P.M.G., Schippers, G.M., (2008) Psychotherapy

and Psychosomatics, Vol 77, No. 5

www.personalityresearch.org/papers/allen.