Cognitive Behavioural Therapy
I have stated before that one of the purposes of my blog is to raise awareness about Psychology on this platform, and consequently debunk misconceptions about mental health. Of course, for this, one of the things I would like my readers to accept is that psychology is not a field entrenched within the boundaries of psychoanalysis, and that talking psychology goes way beyond than talking Sigmund Freud and Carl Jung.
The reason why I have pointed this out in my introduction is because in this post I will discuss Cognitive Behavioural Therapy - CBT. A therapeutic approach rooted in the principles of conditioning (learning) theories, which were first proposed by the now known ͚radical behaviourists͛– Pavlov, Wolpe, Skinner – the very figures who disapproved of the theoretical and subjective methods of psychoanalyses and worked towards turning psychology into a study that is more observable, objective and measurable.
This is precisely what Cognitive Behavioural Therapy is, and its rapid development is largely to do with its empirical grounding. CBT has demonstrated to be very effective in the treatment of conditions such as OCD, panic disorders and depression. So, this is when I should introduce you to Mr. B, a 50-year-old real client who suffered from comorbid major depression and OCD.
Emotions according to CBT
But, before we further explore Mr. B͛s case, let us first see how cognitive behavioural therapy makes sense of emotions, specifically sadness.
In CBT difficult feelings such as sadness (and anxiety) are seen not only as normal, but also as healthy reactions to the environment and life in general. However, when someone experiences such feelings in their most extreme, they can develop avoidant behaviour (for example, stop engaging in daily activities), which will inevitably distance them from family and friends; in turn, causing feeling of detachment that in most cases leads to suicidal thoughts.
This is precisely what happened to Mr. B, who had been divorced for nearly a decade, with no subsequent romantic relationships, jobless for the past six months, and only saw his teenage children every other weekend. Mr. B lived on his own making ends meet with a disability pension and had been contemplating suicide.
A Pattern of Negative Thinking
Although sometimes depression emerges without any clear causes, most often it arises from life situations that involve some kind of loss. When sadness becomes prolonged and causes psychological pain, it triggers a pattern of thinking in which the person gets stuck. It goes pretty much like this:
Negative thoughts > triggering low mood > prompting more negative thoughts > lowering the mood further, and so back to the beginning.
This is a notion that reminds me of a study I came across not long ago (it was not CBT related) which demonstrates that negative emotions also trigger bad memories. Indeed, in some clinical environments it has been noticed that clients afflicted by major depression have great difficulties in recalling good memories. But, the negative thoughts referred to in the pattern mentioned above are not memory related, they have more to do with what Tim Beck defined, in 1976, as the negative cognitive triad - negativity towards oneself, one͛s experience as well as one͛s future. Mr. B experienced all this through ideas that reflected beliefs similar to: "It´s is all my fault", "it will always be this way."
In Mr. B´s case this cycle is particularly serious because it increases his level of anxiety and aggravates his obsessive compulsive behavior. Prior to treatment Mr. B carried out several rituals during the day, they included checking whether doors were locked, and taps and light switches were off. In more difficult days Mr. B would check if the light switches were off even when the rooms were in absolute darkness. This was the way he found to cope with the terrifying, intrusive thoughts of having his house broken into.
Don͛t forget I mentioned earlier that his depression coexisted with OCD.
The Case Study
In neuropsychology a case study is the in-depth study of a single individual using a range of different methods.
Now that you have become acquainted with Mr. B and with how CBT interprets depression, I can present the aim of the case study:
To evaluate how a treatment that combined CBT (particularly behavioural activation) and psychopharmacotherapy improves the psychological health and alleviates symptoms of comorbid OCD and major depression.
Behavioural Activation is a specific method/treatment within cognitive behavioural therapy to treat depression. Here the therapist supports the client to acknowledge, once again, those activities in life which he used to see as enjoyable, but that he has now abandoned (avoidant behaviour). The ultimate goal of this is to guide the client and help him to re-engage in these activities; and consequently, have an increased level of positive reinforcement in his day-to-day life.
Why do it this way? The logic behind this is that by eliminating symptoms of depression (and anxiety) the client will become better prepared to, later on, address deeper psychological issues. Also this also equips the client to see things differently, and therefore attach a more positive meaning to life events and experiences. This is in fact, the fundamental concept in cognitive behavioural theory: it is not so much the situation that prompts emotional reactions; but rather the meaning that the person concerned associate to it. The meaning will then be a result of the interplay between the individual͛s personal history, overall life context and current mood state.
At the end of the 21-month-treatment, Mr. B, who had been completely avoidant, had finished a technical course, was about to start a six-month computer training, and had two potential job positions awaiting him.
This considerable change in Mr. B͛s behaviour and mindset was a result of a highly structured therapeutic program based on a shared understanding and collaborative work, where he was the authority in his own distress and the therapist through his specialized knowledge of depression offered alternative ways for Mr. B to see and experience the world through challenging his negative beliefs.
A range of cognitive techniques can be used in this specific treatment strategy. In this very case, Mr. B was asked to keep a diary where he recorded his thoughts and feelings, he undertook psychometric tests, and took several different psychopharmacological drugs - one at a time throughout the twenty one months (clomipramine, duloxetine, buspirone and lithium). The drugs were prescribed by a psychiatrist who worked in conjunction with the therapist.
The observable and measurable aspects of Mr. B’s treatment
In many ways Mr. B͛s treatment progress and outcome are observable. In his pre-treatment assessment Mr. B was identified as a fully avoidant individual, presenting poor self-care, self-deprecating thoughts, suicidal ideation and compulsive behaviour. After a period of twenty one months he was functional in household activities, self-care and social events. Mr. B himself reported "...my mind is sharper and in more control of my thoughts". Subsequently to stopping taking lithium he also claimed to be feeling more energetic in his daily activities.
As for the measurable aspects, Mr. B demonstrated a decrease in compulsive and obsessive behaviour, depression, anxiety and stress. With ratings of obsessive compulsion going from 31 to 15, depression ratings going from 47 to asymptomatic levels as well as anxiety, where ratings were seen to go from 40 to asymptomatic levels too – These were all measures obtained from the psychometric tests mentioned earlier. Finally, Mr. B presented a gradual decline in the frequency of checking behaviours throughout the 21 months, which at the beginning was at a mean of 101 per day and steadily went down to a mean of 19 per day.
What does this case study tells us?
- That a treatment combining behavioural activation and psychopharmacotherapy is efficient in alleviating symptoms and improving the psychological health of the client.
- That a long-term treatment combining behavioural activation and psychopharmacotherapy effectively treats comorbid OCD and depression.
- It indicates that cases of comorbid disorders that include severe depression may see positive outcomes when treated with behavioural activation.
But it is also important to notice that not all individuals will necessarily benefit from cognitive behavioural therapy. Not rarely, it is seen that one kind of approach will suit a person better than another. Mr. B himself previously attempted to treat his comorbid conditions with psychoanalysis; but experienced no significant improvement in his psychological health and overall well-being. It is also important to note that his was a prolonged treatment, something which the author of the paper highlights as one of the contributing factors for the successful outcome.
Criticism
Not surprisingly the main criticism towards the cognitive behavioural approach comes from psychoanalysts, who claim the elimination of symptoms is not the same as targeting the real cause of the difficult emotional state. Psychoanalysts argue that what this most likely will do is to actually make the ´suppressed´ symptom reappear in the form of ´neurosis´.
There has been no evidence for this, however. Plus, the effectiveness of cognitive behavioural therapy in the treatment of conditions such as social phobias, PTSD, OCD and a few others is nowadays undisputable due to the evidence available.
Reflection
Now that you have a better understanding about cognitive therapy, I would like to ask you to reflect on a few questions:
Do you agree with the behaviourist notion that proposes that it is not the situation per se that causes emotional responses; but rather the meaning attached to it?
Whenever you feel sad or anxious do you also resort to strategies that alleviate the symptoms of your difficult feelings?
[Original Content by Abigail Dantes 2018]
Reference list:
Arco, L. (2015), A case study in treating chronic comorbid obsessive-compulsive disorder and depression with behavioural activation and pharmacotherapy. Psychotherapy, vol. 52, No. 2, pp.278-286
Beck, J. (1995). Cognitive Therapy: Basic and beyond. New York: Guilford Press.
Dear Reader,
Thank you so much for taking the time to read and engage with my work! I wish you all a great weekend ahead 😊
Best.
