Cognitive Behavioural Therapy
Understanding Cognitive Behavioural Therapy
The ‘Frontiers of Psychiatry’ journal describes CBT as the golden standard in the field of psychotherapy, because of its clear research support and continuous development and improvement based on research findings. CBT presently dominates the international guidelines for psychosocial treatments, making it a first-line treatment for most disorders, as noted by the National Institute for Health and Care Excellence’s guidelines and the British and American Psychological Associations.
Cognitive Behavioural Therapy is in fact, an umbrella term for a range of psychotherapy models that successfully bring together the science of psychopathology with behaviourism and cognitive psychology, social learning theories, neuroscience and philosophy. A number of different CBT approaches have gradually evolved over the last 70 years: Exposure Therapy, Behavioural Activation, Stress Inoculation Training, Dialectical Behavioural Therapy, Metacognitive Therapy, Mindfulness, Acceptance & Commitment Therapy and more recently NeuroAffective-CBT are but a few examples.
Frequently Asked Questions
The online offer for mental health support is significant but very confusing and overwhelmed by technical jargon difficult to decipher. In an attempt to bring some clarity, it may be important to start by highlighting that counselling and psychotherapy are terms usually used interchangeably. In addition, there is no agreed hierarchy in terms of knowledge or expertise when it comes to the titles of counsellor, psychotherapist, psychologist or hypnotherapist.
However in United Kingdom, each of these titles are backed by an accreditation which is essentially a licence to practice, administered by one of three main regulatory body such as BABCP (British Association for Behavioural and Cognitive Psychotherapies), UKCP (UK Council for Psychotherapy) and BACP (British Association for Counselling & Psychotherapy). The last two are the principle organisations that can offer a licence for the practice of various forms of counselling & psychotherapy except CBT treatments. BABCP remains the only organisation licencing for CBT psychological treatments. By contrast, the British Psychological Society (BPS) or The Royal Society of Medicine (RSM) are largely academic organisations and cannot accredit psychotherapists for practice. A BPS member would therefore, have to be accredited by one of the three main bodies in order to be able offer psychotherapy.
In summary, a therapist accredited by BACP or UKCP can offer counselling or psychotherapy at the expected standard; a BABCP fully accredited psychotherapist is able to offer treatment via a range of evidence-based therapies such as exposure treatments, cognitive restructuring, trauma processing or mindfulness therapy.
Such accrediting bodies demand a certain standard of training, practice, ethics and continuous personal development. Some of the least demanding organisations are those that regulate the field of hypnosis, for example the GHSC (General Hypnotherapy Standards Council). Some of the hypnotherapy organisations register hypnotherapists with as little as 21 days of training (NVQ 3 level), minimum or no supervision, no personal therapy, no compulsory clinical practice hours and no core profession (psychologist or psychiatric nurse for example). In contrast, the standards of the three main counselling and psychotherapy regulatory bodies (BABCP, UKCP and BACP) are significantly higher with accreditation subjected to intensive post-graduate training between 4 to 7 years, clinical supervision, personal therapy and supervised practice.
Unlike psychotherapists, psychiatrists are medical doctors trained in psychiatry (i.e. psychopathology, mental health diagnosis, pharmacology, etc.) but not in counselling, psychotherapy or any other talking therapies. Clinical psychologists are usually NHS practitioners (but not only) trained at doctoral level in both research methods and talking therapies with no specific focus on a counselling approach.
All BABCP accredited CBT therapists are post-graduates and/or doctoral psychotherapists with a core profession (psychology, psychiatry or psychiatric nursing) specialising in psychological and behavioural treatments, rather than generic counselling. A lot of advertised CBT therapists, do not have a BABCP accreditation which means that they operate outside of regulation and are not always safe practitioners.
More experienced clinicians or therapists can also carry the title of ‘consultant’ which suggests a certain level of seniority, several accreditations, clinical supervision experience and experience as trainers or lecturers.
Anyone can benefit from CBT which can also be used as a life or business coaching tool because of its problem solving properties and SMART approach. But most importantly, CBT comes on top in most outcome studies and randomised control studies, when compared with other therapies for treatments of depression, anxiety, trauma, personality disorders and addictions. A range of methods have been developed specifically to deal with complex emotional issues that are difficult to diagnose, for example NeuroAffective-CBT (NA-CBT) for shame and self-disgust and Dialectical Behavioural Therapy (DBT) for borderline personality disorders, Hypno-CBT for IBS or chronic pains management. CBT has been treating successfully a variety of common problems such as insomnia, binging, gambling, porn addiction, suicidal ideation or self-harming.
NA-CBT in particular relies on an understanding that emotional dysfunction including chronic feelings of shame can be rooted in individuals inability to self-regulate during states of hyper- or hypo-arousal. Underlying neural mechanisms include a loss of top-down prefrontal regulation of amygdala, aberrant cortical processing in the salience network, including insula and cingulate cortex, and sympathovagal changes in the body. Which means that individuals can feel emotionally fragile, moody, unpredictable and lack motivation. Shame, self-disgust, low self-esteem can be found in arrange of mental disorders from the neurotic or personality disorder spectrum but not only.
CBT is an extremely complex and individually tailored psychological treatment which implies that it can only be delivered by someone accredited and with the right level of training and mental health expertise. Lets consider the following case study.
A chronically anxious boyfriend revealed during his assessment for relationship problems that, he experienced significant emotional deprivation during his childhood and he witnessed an unpredictable and explosive parental relationship with regular fights, arguments, cheating and jealousy. He internalised all these emotional childhood experiences in a particularly disintegrated manner and developed a core-belief (or a powerful felt-sense) that he is unlovable and if found out he would be rejected. Such core-beliefs are not usually expressed dialectically with peers or significant others – those become more of an embodied sense-of-self, or a terrible gut-feeling that the individual experiences in a crisis, in the hear-and-now, as a result of the long exposure to all those emotional experiences in his earlier years. Over time, the anxious and rather insecure boyfriend would ensure that he is well defended against all of the possibilities that he will be rejected and covers up for his perceived flaws by developing a number of strategies meant to ensure his survival and even happiness to some degree. Some of his life strategies will therefore be based on the assumption that “I have to always be on my toes in a relationship…the moment I let my guard down, she would cheat on me”, therefore… “It is justified to be jealous; I will stalk her, check on all her movements all of the time, I’ll go through her mobile phone records and pockets (and so on…), in order to be better prepared”, etc.
Any future therapeutic work would help the client identify and target where these complex set of beliefs, associated behaviours and emotions are exaggerated or misguided. During the assessment, the therapist draws a case formulation which explains the predisposing and triggering factors, vicious circles or other vicious traps that maintain the presenting symptoms; this helps educate the client about the relationship between his early childhood experiences, early core beliefs, assumptions, strategies and current critical situations. This formulation or case conceptualisation which is often diagrammatically drawn, would act as the basis for the treatment plan. From this point on, a range of different interventions may be used from problem solving to cognitive awareness, memory processing, gradual exposure, mindfulness or self-hypnosis.