Reading C

The cognitive model was first put forward by Beck (1976). Beck’s model illustrated how emotional problems could be driven by patterns of negative thinking, and proposed that problems could be alleviated by changing thinking processes. Since the 1970s, the cognitive model has been developed, refined and extended. The roles of physiology, behaviour, environment, motivation and process in therapy have all now been considered. The cognitive-behavioural model incorporated the role of a person’s behaviour in the development and maintenance of their problems. The terms ‘cognitive’ and ‘cognitive-behavioural’ are, however, sometimes used interchangeably in the literature. There is now a vast literature of CBT theory and models of varying complexity relating to different client groups, professionals and disorders. We will use a basic CBT model in this book which focuses on the four key elements of psychological distress - thoughts, feelings, physical sensations and behaviour - and the relationships between them. This basic CBT model is illustrated in Figure 3.1. For a wider consideration of the CBT model, we suggest having a look at the ‘five areas approach’ by Williams and Garland (2002) and the ‘five aspects model’ by Padesky and Mooney (1990).

The CBT model hypothesises that situations in themselves do not cause psychological distress, but rather, what is important is the way that people interpret, make sense of and react to situations. People will experience distress if they construe a situation negatively, or react to it in a negative way. Interventions based on the CBT model therefore aim to correct negative biases in thinking processes and behavioural reactions. The CBT model can be used diagrammatically throughout the course of therapy in the form of a ‘maintenance cycle’.

We will now define each element of the CBT model in more detail.

Thoughts and Beliefs

The term ‘negative automatic thought’ (NAT) is often used to describe the cognitive element of distress. The thoughts are automatic as they are not usually under the conscious control of the person. NATs are thought to result from maladaptive core beliefs and assumptions (for a fuller explanation of cognitions, see Chapter 4). Core beliefs and assumptions are developed through our experiences as we grow up. If a person had difficult or traumatic life experiences in their childhood, they are more likely to develop negative core beliefs and assumptions, which result in everyday NATs. These NATs are often experienced as a ‘running commentary’ on a person’s experiences and expectations. As circumstances change as a person grows up, the negative core beliefs, assumptions and NATs may no longer be necessary or appropriate, yet if they have been left unchallenged they may remain.

Feelings – Emotions

Emotions such as anger, sadness, guilt and fear are an important element of psychological distress and are often the reason for seeking help.

Feelings – Physical Sensations

Psychological distress is often manifested physically. Anxiety usually produces marked physiological changes, such as increased heart rate or shortness of breath. Sadness is often accompanied by a lack of appetite.

Behaviours

Another element of psychological distress is behaviour, that is, what a person actually does. This can include changes in activity levels and avoidance, as well as coping strategies such as drug and alcohol use and self-harm.

The cognitive-behavioural model suggests that all these elements of distress are related, so that a change in one element can produce a change in any one of the others. In this way, a negative change in one element can start a ‘negative spiral’, or ‘vicious cycle’, through the impact that it has on the other elements of psychological distress.Cognitive-behavioural interventions break vicious cycles by creating positive changes in one or more elements of the psychological distress.

Cognitive interventions aim to produce changes in thoughts and beliefs, behavioural interventions change behaviours, and interventions such as breathing retraining and relaxation produce changes in physical feelings. Emotions are affected indirectly by all of these interventions. Cognitive work can be helpful to challenge negative beliefs about emotions, and coping strategies for dealing with overwhelming emotions can be developed through behavioural interventions. Psycho-education around emotions is an important precursor to CBT for some individuals (see Chapter 18, Working with Emotions, for a fuller discussion).

In order to illustrate the cognitive-behavioural model, we will now describe some of our own personal experiences. The example we will use is the first experience we had of teaching cognitive-behavioural therapy to mental health professionals. Three of us were involved in this training; two of us had very similar thoughts and one had very different thoughts, resulting in different feelings and behaviours, and these are shown in Figures 3.2 and 3.3.

Figure 3.2 Thoughts about teaching CBT for person 1

Figure 3.3 Thoughts about teaching CBT for persons 2 and 3

As you can see in Figure 3.2, a positive cycle is set as a result of the positive thoughts of person 1. Persons 2 and 3, however, experience a negative cycle as a result of negative thoughts about teaching. All of us experience a mixture of positive thoughts and negative thoughts in our day-to-day lives, but the more negative thoughts we have, the more likely we are to get trapped in negative patterns of thinking, feeling and behaving. These negative patterns are called maintenance cycles, but are also sometimes referred to as ‘vicious cycles’ or ‘negative spirals’. The cognitive-behavioural model suggests that intervening to change any of the different elements of psychological distress, can produce changes in the other elements of psychological distress. Figure 3.4 shows potential CBT interventions that could break the maintenance cycle of persons 2 and 3.

Figure 3.4 Where CBT interventions break the maintenance cycle

Cognitive Interventions

• Mindfulness
• Distraction
• Thought recording
• Thought Challenging

Emotional Work

• Psycho-education
• Coping strategies
• Beliefs about emotions

Physical Intervention

• Controlled breathing
• Relaxation exercise
• Psycho-education about physical symptoms

Behavioural Intervention

• Goal setting
• Graded exposure

Therapist and client will decide together where first to intervene in this maintenance cycle. This will depend on the nature and severity of the client’s problems and will be explored in more detail in Chapter 5, in looking at the structure of therapy and sessions.

Explaining the CBT Model to Clients

In order for therapist and client to work together collaboratively, it is important that the client has a good understanding of the CBT model and treatment rationale. We find that this is best explained by making use of lots of everyday examples, such as the ones illustrated in Figures 3.2 and 3.3. The best examples are ones that are relevant to the client’s own experiences, life and culture. The important point is that different thoughts can arise from the same situation, resulting in different maintenance cycles. We find it helpful to first to first illustrate positive ‘maintenance cycles’: that is, how positive thoughts set up positive patterns of feelings and behaving which reinforce the original positive thought. Having worked through some examples like this, we discuss the point that it is not the situation in itself which causes distress, but the interpretation and meanings that we make in a situation. Some situations or life events will of cause result in very negative thoughts for almost everyone who experiences them, such as losing a job or suffering a bereavement. This is to be expected and entirely natural. People with anxiety or mood-related problems tend to have a bias in their thinking, so are prone to making negative interpretations. It is this bias in thinking that CBT aims to address.

Recognising the Difference between Thoughts, Feelings, Behaviours and Physical Sensations

In order for cognitive-behavioural interventions to be successful, it is important that clients are able to distinguish between the different elements of the CBT model - namely thoughts, feelings, physical sensations and behaviours. These are often mislabelled at the start of therapy; here is an example from our case study. Andy:

Therapist:	What thought did you have when the phone rang?
Andy:	I felt really anxious.

In this example, the client has labelled the emotion rather than the thought. It is the therapist’s job to prompt the client into accessing the relevant thoughts associated with the emotion, for example:

Therapist:	So when the phone rang you felt really anxious. Looking back can you remember what went through your mind at the time the phone started ringing?
Andy:	Yes, I think I was thinking about work.
Therapist:	Okay, so the phone rang and you remember thinking about work. What was it about work that you were thinking about?
Andy:	Well, I thought it would be my boss.
Therapist:	And what did you think that your boss was phoning for?
Andy:	To ask me to do a presentation.
Therapist:	And the thought of doing the presentation made you feel anxious?
Andy:	Yes, because I would make a fool of myself.

The therapist finally elicits the NAT in this example, which is: “I will make a fool of myself”.

Practical Exercise

When teaching CBT to other professionals, we use an exercise to identify thoughts, feelings, physical sensations and behaviours. It is also a useful exercise to complete with clients early on in therapy when confusion around the elements of the maintenance cycle is common. The client needs to be able to correctly identify these different elements of distress before moving on to interventions to break the maintenance cycle. The identification of NATs will be covered in more detail in Chapter 13.

The thoughts, feelings, physical sensations and behaviours listed in Appendix II can be photocopied and cut up into the individuals statements. The task is to sort the statements into groups of ‘thoughts’, ‘feelings’, ‘behaviours’ and ‘physical sensations’. This exercise is not as easy as it first seems. It does not matter if you do not get this 100 per cent right – there are usually discrepancies between people regarding what constitutes a thought and what constitutes a feeling.

The Third Wave of Cognitive Behavioural Approaches

Third-wave approaches combine traditional elements of CBT with various new concepts, including mindfulness, acceptance, metacognition, dialectics and emotions. New therapies have evolved from the inclusion of these new elements. Dialectical behaviour therapy was developed in the early 1990s by Marsha Linehan and colleagues (1993). It includes elements of traditional behavioural and cognitive approaches, alongside dialectics, mindfulness and acceptance. Acceptance and commitment therapy was first developed by Stephen Hayes in the 1980s. It has recently grown in popularity in both mental health and health settings and includes behavioural and cognitive approaches, alongside a focus on acceptance and values (for more information and resources, see www.actmindfully.com.au and https://contextualscience.org).

Mindfulness-based cognitive therapy (MBCT), as its name suggests, seeks to address difficult thoughts and feelings through the practice of mindfulness (for more information and resources, see https://mbct.co.uk/).

In this book, we will touch on how some of the elements of third-wave approaches, mindfulness in particular, can be used within a traditional CBT framework to enhance practice.

Summary

• The CBT model suggests that the way people interpret and react to situations can cause psychological distress.
• Interventions based on the CBT model aim to correct negative biases in thinking and behaviour.
• The model proposes that the elements of psychological distress – thoughts, emotions, physical sensations and behaviours – are related. A change in one can produce changes in the others.
• Third-wave CBT approaches incorporate concepts such as mindfulness, acceptance and dialectics.