This post will look at Cognitive Behavioural Therapy (CBT), its background, its theoretical standpoints and its cohesion or otherwise with Christianity. To end, this post will consider how it can be applied to my own psychological challenge/disability—bipolar disorder.
Background of CBT
Behaviourism arose at the beginning of the 20th century. Its central tenet is that all organisms react to the external environment with a variety of behaviours. These behaviours are learnt and are in direct response to reinforcement, leading to the idea that psychological and psychiatric conditions are largely due to maladaptive learned behaviour (Drummond, 2014). Key early figures in behaviourism’s history include Pavlov, Thorndike, J.B. Watson and B.F. Skinner. But it was not until the middle of the 20th century that treating patients with behavioural methods took root.
In the 1960s Albert Ellis broke new ground by positing that people were not disturbed by negative events but by their beliefs or cognitions about these events. Beck similarly challenged the status quo, by describing negative automatic thoughts (NATs) and how these could be challenged to alter mood. Beck’s interventions for anxiety and personality disorders are still the most widely used for these conditions (Drummond, 2014).
Lately there has been questioning of the existing CBT models and a ‘third wave’ of therapies has emerged, all of which are empirically based and concern themselves with how the patient responds to their cognitions. They also focus less on cognitions and more on behaviours.
CBT has several different elements to it. Firstly it is different in its therapeutic style from some other forms of therapy. It assumes that the therapist does more than just ‘listen’, but that the therapist is active and brings with them a range of skills and ideas about interventions. Secondly, there is a psychological formulation, a picture if you will, of why someone is experiencing difficulties. The picture differs from a diagnosis in that it provides an explanation not just a label. Thirdly, the therapy is goal directed. There is an outcome in sight. Fourthly, it is time-limited. Lastly, there is the use of homework or assignments that the client must complete in between therapy sessions.
Interestingly, there is little evidence that one model or kind of psychotherapy is superior to another (McMinn & Campbell, 2007; Nathan, Stuart, & Dolan, 2000). However, research studies (and there are issues around just what kind of client finds themselves suitable for research studies) have shown CBT to be effective with depression (Hundt, Mignogna, Underhill, & Cully, 2013), anxiety disorders, borderline personality disorder and a variety of other problems (McMinn & Campbell, 2007). According to McMinn and Campbell (2007) between 60% and 90% (depending on who’s list you read) of empirically supported treatments are cognitive-behavioural. For example, the effectiveness of CBT treatment for panic disorder is quite impressive, either on its own or with medication (Roy-Byrne et al, cited in McMinn & Campbell, 2007). Between 50% and 75% of those who complete psychological treatment are free of panic symptoms at the end of treatment and at a two-year follow-up (Craske & Barlow, 2001; Western & Morrison, 2001; both cited in McMinn & Campbell, 2007).
CBT’s understanding of human nature
In CBT theory the emphasis is placed on the description and challenging of the links between thinking, feeling and acting. CBT therapists rely upon patient compliance with its technical procedures and the personal qualities of the practitioner to maintain the therapeutic work (Ryle, n.d.). There is at CBT’s core a belief that there is a relationship between thoughts, feelings, physical sensations and behaviour. The CBT model hypothesises that situations in themselves do not cause psychological distress, but rather what is important is the way people interpret, make sense of and react to situations (Simmons & Griffiths, 2009).
There is also a widely-held view of Ellis’, the ABC model. In this model ‘A’ the activating event or adversity contributes to ‘C’ the consequences, both behavioural and emotional. However, ‘B’—beliefs about the activating event—moderate the response (Drummond, 2014). In other words, what one believes about an event or circumstance shapes one’s response to that event.
CBT’s understanding of identity
Because CBT is a range of therapeutic interventions and theories (some theories built from the interventions themselves rather than ‘theory first then practice’ [Drummond, 2014]) there is no one ‘view’ of identity and human nature. However, what can be said is that each person’s personality is unique and must be understood as such (Jones & Butman, 2011). For example, the core of Ellis’ Rational Emotive Behavioural Therapy (REBT) is that a person’s thoughts are central to understanding that person (Corey, 2013).
CBT’s understanding of psychopathology and the change process
Meichenbaum took the understanding that a person’s thoughts are central to their identity and proposed a three-stage model for effective change. First, the client must become aware of thoughts relevant to the problem being experienced. Next, therapist and client must develop alternative thoughts that can believably replace the troubling thoughts. Finally, the client must implement these thought changes and begin to enjoy the benefits of non-destructive thinking (Jones and Butman, 2011).
Beck introduced ‘schemas’ to the cognitive model. A schema is a structure that contains a representation of reality that sits below conscious awareness. Whereas dysfunctional negative automatic thoughts (NATs) are responses to situations, schemas contain general rules and assumptions about the world (Jones and Butman, 2011).
Hayes in his third-wave Acceptance and Commitment Therapy (ACT) tries not to modify an irrational thought (which Beck would do) but instead aim to understand and then alter the contexts in a client’s life that permits the negative thought to function. Thus, by mindfully observing the irrational thought its problematic functions loosen—a shift in internal contexts—and the function becomes acceptable (Jones and Butman, 2011).
CBT and the Christian worldview
Jones and Butman (2011) in their most helpful and insightful review of modern psychotherapies hold that CBT is arguably the psychotherapy least antagonistic to a Christian worldview. As they say, “of all the various psychotherapies perhaps the cognitive therapy view, faulty as it is, comes closest to a Christian view of freedom” (p. 232).
Certainly the behavioural aspect of CBT doesn’t gel well with Christianity; there is a determinism inherent in behaviourism that Jones and Butman (2011) say we should reject. But, they say, modern CBT has moved away from its strictly behavioural roots to encompass humanism, existentialism, social constructionism, generic forms of spirituality, and contemporary psychodynamic theory. That is a daunting number of different theories to consider from a Christian viewpoint, but equally it allows a freedom to create one’s own theory that allows for a Christian worldview.
Cognitive therapists are perhaps distinctive within all of the psychotherapies for being open with clients about the change process, and in trying to enlist the client as a collaborator, carrying with such openness views of agency, choice and freedom. Jones and Butman (2011) note the similarities between Beck’s notion of conscious control and the apostle Paul’s instruction to renew one’s identity by renewing one’s mind (Rom 12:1-2). Both Beck and Paul assume humans can develop both self-awareness and an ability to change one’s views of self in relation to the world.
Cognitive therapies reside in a midway point between the complete freedom and autonomy of humanistic theories and the hard determinism found in behaviourism. Both cognitive therapy and Christianity assume a person has choice and that choices have consequences (Deut 30:19; Prov 22:1; Rom 6:16).
The third-wave therapies—for example, Acceptance and Commitment Therapy (ACT)—emphasise constructing one’s own path and the emphasis of the therapies on mindfulness suggests a freedom in how one appraises and accepts a situation. Mindfulness and constructivism suggest an autonomous view of the mind that makes cognitive therapy “more acceptable to Christians as an integrating view of persons” (Jones and Butman, 2011, p. 234).
Integrative Psychology (IP) has been put forward by McMinn and Campbell (2007) as a way of integrating psychology and Christianity; they say that their tripartite approach (symptom-focused, schema-focused, and relationship-focused therapies), is rooted in cognitive techniques, but not exclusively so. Jones and Butman (2011) give McMinn and Campbell’s approach a cautious ‘thumbs up’, but note that much research into the approach still needs to take place.
CBT and me—bipolar disorder
The jury is mostly in on whether CBT is an effective treatment for Bipolar Disorder (BD). Basco and Rush (2005) in their book on the topic say that numerous studies have proven the efficacy of CBT in treating BD but Lynch, Laws and McKenna (2010) argue that CBT has problems treating relapses in the disease. In reviews of the literature, Gonzales-Pinto and colleagues (Gonzalez-Pinto et al., 2004) and Hollon and Ponniah (2010) found that CBT diminished depressive symptoms and improved the quality of the BD sufferer’s life, with a reduction in both frequency and duration of mood episodes, as well as higher degrees of compliance and fewer hospitalizations (see Costa et al., 2010). Since my own principle expression of BD is depression (with infrequent hypomania), CBT’s efficacy in this regard is welcome.
Of particular interest to me is the use of computer- and internet-based CBT treatments. Bergström (2010) reports on the successful use of internet-based self-help programs for depression and panic disorder when self-help programs are accompanied by brief therapist email support. El Alaoui et al., (2013) discuss internet-based CBT (ICBT) versus traditional face-to-face CBT treatments (including group-based treatments [GCBT]) for panic disorder. They find that ICBT and GCBT work equally well. Arnberg and his colleagues (2014) reviewed the literature on ICBT for effectiveness with mood and anxiety disorders and found that ICBT is a viable treatment option for adults with depression and some anxiety disorders. Andersson and Cuijpers (2009) reviewed the literature on internet and computer-based psychological treatments for depression and found they hold promise as potentially evidence-based treatments of depression. No studies have been done with ICBT and BD, however, and it is too soon for research to be conducted on the new smartphone and tablet applications such as SnapshotApp, PTSD Coach, Gratitude365, Optimism, Smiling Mind, and Breathe2Relax, and the just-released ACTCompanion by Russ Harris, inter alia.
Also of interest is the finding by Mota Pereira (2014) that Facebook has useful properties for sufferers of treatment-resistant major depressive disorder, providing the patient’s regular psychiatrist is a ‘friend’ and interacts with them on Facebook. This finding is perhaps challenging for those practitioners used to traditional ideas of ‘boundaries’.
This post has given a brief background to where CBT came from, its shifting design and its current formulation. Also noted is its views on personal identity, its understanding of human nature and how it approaches the change process. Of particular interest was its abutment with Christian viewpoints and how it has been used by two Christians to create a therapy that appears to hold some promise. Finally, this essay looked at CBT and its own use with my particular psychological condition, Bipolar Disorder. It has been found to be very beneficial in the management and treatment of Bipolar Disorder.
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Jones, S. L., & Butman, R. E. (2011). Modern psychotherapies: A comprehensive Christian appraisal (2nd Edition). Westmont, IL, USA: InterVarsity Press.
Lynch, D., Laws, K. R., & McKenna, P. J. (2010). Cognitive behavioural therapy for major psychiatric disorder: does it really work? A meta-analytical review of well-controlled trials. Psychological Medicine, 40(01), 9-24. doi: 10.1017/S003329170900590X
McMinn, M. R., & Campbell, C. D. (2007). Integrative psychotherapy: Toward a comprehensive Christian approach. Downers Grove, Illinois, USA: IVP Academic.
Mota Pereira, J. (2014). Facebook enhances antidepressant pharmacotherapy effects. The Scientific World Journal, 2014, 6. doi: 10.1155/2014/892048
Nathan, P. E., Stuart, S. P., & Dolan, S. L. (2000). Research on psychotherapy efficacy and effectiveness: Between Scylla and Charybdis? Psychological Bulletin, 126(6), 964-981.
Ryle, A. (n.d.). Critique of CBT and CAT. http://www.sagepub.com/upm-data/47043_07_Critique_of_CBTand_CAT.pdf
Simmons, J., & Griffiths, R. (2009). CBT for beginners. London: SAGE.