Cognitive Behavior Therapy (CBT)

Cognitive Behavior Therapy (CBT)

CBT represent the hybrid of behavioral strategies and cognitive processes with the goal of achieving behavioral and cognitive change.

CBT shares three fundamental propositions:

Cognitive activity affects behavior

Cognitive activity may be monitored and altered

Desired behavior change may be affected through cognitive change

Historical Development

Victor Raimy (1975) has traced the history of CBT from ancient Greek and Roman philosophers to modern day theorists. He cites the example of Epictetus who highlighted the role of cognitive factors in causing emotional disturbance. As Epictetus noted, “Men are disturbed not by events but by the views they take of them”. In the same vein, Kant proposed that mental illness occurs when a person fails to correct his/her “private sense” with “common sense”. Alfred Adler viewed Kant’s “private sense” as “mistaken opinions” that underlie neurotic behavior. Modern day theorists use such terms as “biased appraisal processes”, “cognitive distortions”, etc. to describe the role that cognitive factors play in emotional disturbances and maladaptive behaviors.

Two specific lines of theorizing and research have contributed to the emergence of a CBT approach. One is cognitive-semantic therapy and the second line derives from learning theory behavior therapy. Besides, a number of specific factors led to the development of CBT, such as,

Non-mediational approach was not expansive enough to account for all of human behavior;

Psychodynamic model with its emphasis on unconscious processes, historical material and long-term therapy was rejected by Beck, Ellis;

Targets of intervention by their very nature sometimes made interventions of a non-cognitive nature irrelevant, e.g., behavioral treatments for compulsive behavior were established even while obsessive thinking was not targeted for change;

Cognitive psychology developed a number of meditational concepts which the behavioral perspective was unable to explain;

A number of theorists and therapists clearly identified themselves as being cognitive-behavioral in orientation such as Beck, Ellis;

Research publications showed CBT to be more effective in the treatment of mental disorders, e.g., depression than the behavioral therapies.

CBT highlights the interdependence of multiple processes involving the individual’s thoughts, feelings, behaviors, and environmental consequences.

There are sequential stages of the change process that implicitly underlie CBT. The first stage in the change process involves training the client to be a better observer of his/her own behavior. This stage serves two additional purposes first, the client becomes aware of pertinent data. Second purpose is to contribute to a translation or a reconceptualization process.

The second stage of behavior change helps the client to develop adaptive thoughts and behaviors.

The third stage of behavior change involves the clients’ cognitions and feelings concerning change. During this phase the therapist works with the client to consolidate changes, promote generalization and maintenance of treatment effects and lessen the likelihood of relapse. During therapy, these three stages overlap and consistently recur. CBT represents not simply a set of therapeutic techniques, but rather a conceptualization of the change process that supposedly underlies all therapeutic procedures.

There are three major classes of CBTs, namely, coping-skills therapies (e.g., anxiety management training, stress-inoculation training); problem-solving therapies (self-control therapy, problem-solving therapy by D’Zurilla & Goldfried); and cognitive restructuring methods (REBT by Ellis, CT by Beck).

Rational Emotive Behavior Therapy (REBT) by Albert Ellis

Albert Ellis, a clinical psychologist and at the time a practicing psychoanalytically oriented psychotherapist, initiated the development of REBT as a separate therapeutic system in 1955. Ellis had become disillusioned with traditional psychoanalytic therapy because clients rarely gave up their presenting symptoms or they developed new ones. This lack of progress occurred even though his clients could achieve insight by connecting the events of their early childhood to their present emotional disturbances. Ellis came to realize that the problem was that clients continued to actively re-indoctrinate themselves with the irrationalities they had invented and learned in their childhood. Ellis’s early practice and thinking culminated in a book on the psychotherapeutic principles of REBT-----Reason and Emotion in Psychotherapy (Ellis, 1962).

REBT is a comprehensive approach to treatment and education that employs cognitive, emotive, and behavioral approaches. It advocates a humanistic, educative model of treatment as opposed to a medical model.

The Basic Theory of REBT

Causes of Emotional Disturbance: emotional disturbance has several important cognitive, emotive, and behavioral sources. Humans are not only born easily disturbable, but they live in a social and physical environment, so that their “healthy” and “unhealthy” behaviors are caused by the interactions among their innate predispositions and their external, particularly social milieu.

Following the views of several philosophers such as Buddha, Epictetus, REBT holds that people largely are responsible for their emotional disturbances and that they overtly and consciously and unconsciously “choose” to disturb themselves. Consequently, they can consciously and actively choose to undisturb and to fulfill themselves.

The REBT posits an ABCD model. People start with goals (Gs), usually to remain alive and reasonably happy and then often encounter activating events or adversities (As) that block or thwart their desire for success, love, and comfort. They then tend to create or construct cognitive, emotive, and behavioral consequences (Cs) about these As-----particularly inappropriate or self-defeating feelings of anxiety, depression, and rage, as well as such dysfunctional behaviors as withdrawl, procrastination, and compulsions. They construct these self-sabotaging Cs largely by their beliefs (Bs). These consist of first, rational beliefs (rBs), which are preferences and wishes and of, second, irrational beliefs (iBs), which are dogmatic musts and imperative demands. Thus, when adversities like failure and rejection occur or when people imagine or make occur at point A, they choose rational beliefs (rBs) at point B---such as “I don’t like failure and being rejected, but it’s not the end of the world and I can still find some degree of happiness”-----and they then feel appropriately (self-helpingly) sorry and disappointed, and try to change what is happening at point A. And they also choose irrational beliefs (iBs) at point B----such as, “I absolutely must not fail or be rejected. How awful. What an incompetent and unlovable person I am!” ---- and they then inappropriately  (self-defeatingly) feel anxious, depressed, and self-hating.

Disturbance about Disturbance: once people disturb themselves, they largely construct secondary disturbances or disturbances about their disturbances. Thus they make themselves anxious about their anxiety, depressed about their depression.

Low Frustration Tolerance (LFT): People not only disturb themselves by their performances but also by their LFT, as they destructively demand that other people and external conditions absolutely must act and be exactly the way they preferred them to act.

Initially, Ellis had listed ten major irrational beliefs (iBs) that according to him people largely use to upset themselves, however, after using REBT for several years he realized that the original 10 iBs could be put under three main headings, and that each of these core iBs included an absolutist, rigid should or must. Thus,, (1) “I (ego) absolutely must perform well and win significant others’ approval or else I am an inadequate , worthless person”. “You (other people) must under all conditions and at all times be nice and fair to me or else you are a rotten, horrible person!” (3) “Conditions under which I live absolutely must be comfortable, safe, and advantageous or else the world is a rotten place, I can’t stand it, and life is hardly worth living”.

The goal of REBT is to help the clients learn to change or modify these irrational beliefs by disputing (D) such beliefs.

Cognitive Therapy (CT) by Beck

The initial impetus for the rationale and procedures of CT came from Aaron Beck’s early interviews with depressed clients. His early descriptions of depressed patients emphasized the negative biases and cognitive distortions. These biases and distortions are distinctive to depression.

Beck posits that the depressed patients exhibit distorted information, which results in a consistently negative view of him/herself, the future, and the world, which has been referred as “cognitive triad”. Beck’s cognitive model of emotional disorders states that in order to understand the nature of an emotional episode one must focus on the cognitive content of one’s reactions to the upsetting or stream of thoughts.

The cognitive distortions may arise out of schemata and/or cognitive errors. Schemata are the underlying cognitive structures that organize the client’s experience and that can form the basis for the individual instances of bias or distortions. These schemata are thought to represent the core of the cognitive disturbance, and can be called “core beliefs”.

Cognitive Errors: are the thinking errors that we are all subject to, and that occur more frequently during affective episodes. Some of these errors are arbitrary Inference, selective abstraction, overgeneralization, magnification and minimization, personalization and dichotomous thinking.

Clinical Applications

CT combines behavioral and cognitive methods to bring the desired cognitive changes. Some of the behavioral and cognitive methods are:

Behavioral Methods:

Self-Monitoring: clients are asked to for atleast one week keep a careful hour by hour record of their activities and associated moods. They may also be asked to record their mood on a simple 0-100 scale. This record can serve several functions:

Acquaint the therapist with the way the client is spending his/her time;

Serves as a baseline against which later records can be compared;

A number of hypotheses can be tested;

A cue to the client’s memory;

Based on good or bad moods, certain activities can be sought out or avoided

Scheduling Activities: can serve several purposes, such as: to increase the probability that the client will engage in activities that he or she has been avoiding; to remove decision-making as an obstacle in the initiation of an activity. Such activities can come from three domains: (1) those that were associated with mastery, pleasure, or good mood during self-monitoring; (2) those that had been rewarding in the past but that the client has been avoiding of late; (3) activities agreed upon by the client and therapist that may be rewarding.

Graded Tasks: easier or simpler aspects of larger tasks are attempted first so that initial successes may provide an impetus for the more difficult aspects of the task.

Cognitive Method: Daily Record of Dysfunctional Thoughts (DRDT). It has four columns, namely, situation, negative beliefs, emotional consequence, and the counter response to the negative beliefs. The DRDT can be worked on in the session as well as independently by the client.

Evaluation of CBT: inspite of the widespread attention that REBT has enjoyed, little research attests to its efficacy, especially for carefully diagnosed clinical population. It appears to be inferior to exposure-based therapies in the treatment of anxiety disorders such as agoraphobia, social phobia, and OCD. It may be most useful in helping basically healthy people to cope better with everyday stress and perhaps in preventing them from developing full-blown anxiety or depressive disorders.

In contrast, the efficacy of Beck’s CT has been well documented. Research suggests that these approaches are extremely beneficial in alleviating many different types of disorders. For depression, CBT is at least comparable to drug treatment for all but the most severe cases. It also offers long term advantages, especially with regard to the prevention of relapse. CT also offers effective treatment for panic disorder, GAD, and bulimia nervosa, conduct disorder in children, substance abuse, and certain personality disorders.

The CBT is routinely used nowadays with success; however, the active ingredients of CBT are now a focus of debate and research.

Patricia Uberoi, a sociologist invested in the collection and study of calendar art since the mid 1960s, defines Calendar art or Bazaar Art as “a particular style of popular colour reproductions, with sacred or merely decorative motifs... This art style extends beyond calendars and posters. In fact, it is a general 'kitsch' style which can be found on street hoardings, film posters, sweet boxes, fireworks, wall paintings, and advertising, and in the knick-knacks sold in fairs.” As such, calendar art has provided the nation with a visual vocabulary to communities otherwise divided and separated from each other. Being among the pioneers of academic writing on this form of popular print culture, Uberoi has written several essays on the theme of nation-building and on the representation on women, goddesses, children and Sikh community in such art.

One such essay called “Unity in Diversity? Dilemmas of Nationhood in Indian Calendar Art,” Uberoi focuses on the visual representation of the ideal of secularism in the popular print culture of post-colonial India with respect to nation building. Her study reveals that a tension exists between a relatively egalitarian understanding of the ideal of 'unity in diversity' that conceives all religious traditions as equivalent sources of truth, and a 'majoritarian' understanding where all other religions are appropriated to a Hindu order. A set of 'Sikh' calendars of the period illustrates this tension and the delicate relations of similarity and difference, affinity and hostility between the Hindu and Sikh faiths in post-colonial India. Uberoi also shows how these images, when reworked in new contexts, sometimes lead to separatist confrontation, and other times, to conciliation.

Uberoi's essay is inspired by Shahid Amin, a well-known historian, who commented on the “fate of Indian secularism” with special reference to the print image of “four fair, cherubic and physiognomically almost identical young boys” in its four quarters. With the print bearing the slogan “Ham sab ek hain”, these four boys represent the four religions of Hindu, Islam, Christianity and Sikh. According to Amin, this image has become a “dead metaphor” with repetitive printing over time, not only losing its very meaning but also its power to excite and provoke people. Amin also points out the caricaturizing and stereotyping of the Muslim 'other' in this image. The “special head gear” of fez, an inverted waste-paper basket is only a fancy-dress item in real life, “put there by the advertisers of our multi-religious nation state.”

Hum Sab Ek Hain (We all are one). Artist: Probably Anil Sharma. Published 1990.

Uberoi, however, also observes another point that Amin does not – that the Sikh boy is also differentiated with the kerchief on his top-knot and his open neck shirt. But what strikes Uberoi more is “prominent central medallion around which the four children are symmetrically arranged” - the figure of Mother India, holding a burning torch in one hand and a national flag in the other. She has golden halo and a lion as her vehicle, both of which align her with the goddess Durga, a Hindu deity. She stands on the map of India that particularly signifies the Hindu holy sites of Mansarovar Lake and Mount Kailash. This makes clear that the nation, claiming to uphold the egalitarian message, “We all are one,” is actually re-inscribed as a Hindu polity. The naturalness of the Hindu child with uncut hair, now seems to take on a new meaning and set against the other boys, who have been 'marked' in some way or the other.

Immediately after Independence, India was faced with the challenges of nation building - of securing its frontiers, of achieving material progress and prosperity, and of elimination of poverty. In all this, calendar art offered solutions all of which were presented as equally productive, therefore providing an almost utopian vision of a country where all contradictions are resolved. However, there was another important challenge – of creating unity out of diversity. Different religious communities, castes, classes, men and women, tribes – all had to be brought under the umbrella of a “homogeneous, democratic and just national society.” To signify national unity, many signs were deployed – the map of India, the national flag, Hindu deities, figure of Mother India, the Mother Cow, the child, the couple, etc. However, this representation in calendar art also led to a continuing dilemma, which was strong enough to cause partition in the country. Uberoi, as many others, deals with this dilemma.

Chaurasi Dev Darshan (Vision of the 84 deities). Artist: B.C. Sharma. Published 1987

The idea of “Ham sab ek hain” does seem very routinized and meaningless today. Through the last century, the variety of visuals of religious pluralism has gone down. It foregrounds the tension between an egalitarian, and a Hindu majoritarian view of the constitution of India as a multi-religious society. This tension is definitely not a new expression in calendar art, as Uberoi has studied by taking pictures from different time periods. Uberoi basically suggests that all of these images counter-pose an inclusivist religious visualization of secular ideology of independent India against the majoritarian view where all other religions are brought under the umbrella of Hindu religious nationalism. However, she leaves a hope and expands the scope by suggesting other modalities.