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Cognitive behavioural therapy and psychological treatment of thoughts

Epictetus a Greek said, “Men are disturbed, not by things, but by the principles and notions which they form concerning things.” (--------). In other words, behaviors and feelings are affected by how people think i.e. cognition. This forms the basic premise of Cognitive behavioural therapy which is viewed as a "psychological treatment of thoughts." This paper will look at the basic elements of CBT and some of its drawbacks.

Cognitive Behavioral Therapy (CBT) is influenced by two schools of psychology: behavioral and cognitive therapy. According to Westbrook (2008) behavior therapy occurred as a rejoinder against the Freudian psychodynamic paradigm that had subjugated psychotherapy from the nineteenth century onwards.  The theory was underlying classical conditioning that was based on Pavlovs (1927) work and operant conditioning based on Skinners (1938) classical conditioning, which incorporates a naturally occurring or a conditional stimulus, which has not previously formed a particular response, becomes allied with an unconditional stimulus, which produces the response. This result in the conditioned stimulus will obtain the response that the unconditional stimulus produces (psychologyandsociety.com). Operant conditioning is a process of learning, which transpires through rewards and punishment for behavior (Wagner). Skinner believed that motivations and interior thoughts could not be used to elucidate behavior. Instead, Skinner suggested, individuals should look only at the external, recognizable causes of human behavior (Wagner). However, in America during the 1950s and early 1960s Aaron Beck a medical doctor, psychoanalyst and a psychiatrist saw that his patients were not going to improve with analysis (Webber 2008). Both Beck and Albert Ellis noticed that patients were held back due to negative thoughts (Webber 2008). There was a great impact in psychology when Beck published his book on cognitive therapy for depression (Beck et al 1976). In addition, research showed that CT was as effectual a treatment for depression as anti-depressant medication (Rush et al 1977). This was because CT helps individuals overcome obscurity by identifying and changing dysfunctional thinking which leads to an emotional reaction which results in a certain behavior. Cognitive therapy helps individuals to develop skills for modifying beliefs, identifying distorted thinking and changing behaviors (Beck 2008). Over years, cognitive behavioral therapy and behavioral therapy grew and influenced to the amalgamation know as cognitive behavioral therapy.  

The essential premise of CBT is that peoples’ thoughts influence how they feel physically and emotionally resulting in the alteration of what they do (Williams et al 2002). Aaron Beck had initiated cognitive therapy for the treatment of depression. Beck and other researchers had developed methods for applying cognitive therapy to other psychiatric problems, such as anger control problems, substance abuse and panic disorder. The National Institute for Clinical Excellence (date), has stated the CBT uses techniques from behavioral therapy and cognitive therapy. Kinsella (2008) mentions that CBT is an evidence-based treatment that seeks to address patients’ existing problems with highly structured the therapeutic sessions. This treatment is goal oriented where goals are agreed upon between the therapist and patient in terms of improving the patient’s difficult emotional states and unhelpful prototype of behavior and thinking. CBT is a comparatively short-term (average 12-18 sessions) brief therapy which can be used for a wide range of psychological disorders such as: anxiety, depression, substance abuse, personality disorder and anorexia nervosa amongst others. Depending on the individual’s needs CBT delivery varies, nevertheless, the main goal of CBT is to make the patients aware of their ‘incorrect beliefs’and eventually challenge them; these beliefs are usually involuntary, however, they critically affect how people respond to situations (virtual medical centre).

According to Westbrook (2008) cognition mediates the emotional responses and behaviors. In other words, an individual’s belief, thoughts, interpretations about themselves or the situation in which they find themselves essentially constructs the meaning they give to the events in their lives. To illustrate this point further in everyday life, if we were to ask individuals what makes them happy, angry, sad etc. often the answer would be a situation or accounts of events. For example “I am fed up because I have had a quarrel with my boyfriend.” If an experience automatically gave rise to an emotion in such an uncomplicated way, then it would follow that all individuals with the same situation would feel the same emotion. However, this is not the case- individuals react to a lesser or greater degree, individuals react in a different way to similar events; therefore it is something else which determines the emotions. The ‘C’ in CBT is the ‘something else’ also know as cognition, by way of explanation the interpretations people make of the event. The idiosyncrasies of an individual influences the manner in which a person reacts to an event so that, one person’s reaction may seem idiosyncratic to another. This is due to the fact that each person has behavior patterns typical to him or her. The ‘B’ in CBT still uses part of the legacy from Behavioral therapy however in CBT behavior reflects on what we do as a central part in changing the emotional state or maintaining the individual. CBT demonstrates that behavior has a strong impact on thoughts and emotions. Therefore, any kind of behavior, rules the way you think and react. 

Cognitive therapy focuses on change at various levels of cognition; negative automatic thoughts (NATs), dysfunctional assumptions (DA) and core beliefs. The term negative automatic thought is self-explanatory and occurs without the realization of the person. To identify them one requires a concerted effort. According to Kinsella (2008), NATs present themselves through specific events and situations though they may vary in intensity. However, People can be conscious of NATs in their persona or notice their existence by monitoring them. Nevertheless, they are so ingrained in a person that they may or may not be noticed at all. NATs emanate from the essence of one’s beliefs and manner of living, representing daily experiences. In addition, they influence a person’s mood constantly and have a central role to play in CBT.  NATs are so part of an individual’s existence that to view them objectively is a feat. The harsh reality is that NATs are always going to be part of human nature and temperament, so it is up to every individual to control them whenever they surface. 

Dysfunctional assumptions (DA) or intermediate beliefs bridge the gap between NATs and core beliefs. As per Westbrook (2008), in nature, DA represents guidelines for living, being more specific in application than Core Beliefs but more general than NATs. The reason they are dysfunctional is because of their rigidity and this leads to hindrances while coping with setbacks and complications in life. DAs are sometimes not easy to detect as they are inferential in nature.  Nevertheless, they are approved of by some cultures and re-enforce attitudes like success. DAs are made of attitudes, rules and assumptions, symbolized as ABC by therapists (Ellias 1962 and 1977 cited in Curwen 2000). “A” stands for activating an event; “B” stands for belief and “C” stands for consequence (Curwen 2000) . DAs are introduced towards the latter half of therapy after people have learnt to cope with NATs. Modifying DAs may also prevent people from facing psychological problems repeatedly (Westbrook 2007)

Grant (2004) suggests core beliefs are also referred to as schemas or schemata. They signify the fundamental view we have about people, our world and ourselves. These beliefs appear early in life when we learn our first and lasting lessons. Core beliefs are, in essence, our realities. Therefore, they are not as readily alterable as automatic thoughts (which are the products of core beliefs). Longer-term cognitive therapy will focus a great deal on core beliefs. Nevertheless, core Beliefs encompass domains related to self, basically negative aspects of self- like failure, the unfairness in the world and inferiority complexes (Kinsella 2008). People find it difficult to distance themselves form core beliefs and tend to define themselves based on their content. Lately, therapists have devoted much time to core beliefs and have shown how they play a vital role in maintenance of varied long time psychiatric problems (Kinsella 2008).

The key principles of Cognitive behavioural therapy that have been adopted from Beck (1976), Beck et al (1985) and Beck (1995) cited in Wills (2008) are broken into four categories. First, a base from which to help patients: CBT requires a good therapeutic relationship and collaboration. Second, a way to understand patients and their problems: besides a therapeutic relationship CBT is based on assessment and formulation. Third, a strategic posture for helping efforts: CBT is relatively short; it is problem focused and goal-oriented. CBT focuses on present- time issues therefore it is structural and directional in addition CBT is educational. The fourth, is a skills base for implementing strategies such as: Socratic questioning, CBT makes regular use of homework tasks and it uses a variety of techniques to change thinking, mood and behaviour.

A base from which to help patients: therapeutic relationship and collaboration

The efficacy of cognitive and behavioral techniques is dependent, to a large degree, on the relationship between the therapist and patient. Beck et al (1979) explain that the relationship requires therapist warmth, accurate empathy and genuineness. The therapeutic style in CBT is very directive particularly in the early stages of therapy.

The therapist is sensitive in balancing this with communication and an empathetic understanding by being “with” the patient, together with grasping the clients meaning (Curwen 2002). The therapeutic outcome is influenced by the quality of patient-therapist relationship (Orlinsky et al 1994). While one may get the impression that CBT is just about talking, it lays a strong emphasis on action, with a strong emphasis on the patient assuming a central role in initiating change (Kinsella 2008). Therefore, in any CBT intervention the focus is on intrinsic self help. According to Kinsella (2008) the aim in CBT is skill building, where the patient is taught a set of skills that can be used on a long-term basis to effectively embark upon or administer problems. Although one cannot undermine the importance of the therapeutic relationship, it is not seen as the sole vehicle for change in CBT. A greater emphasis is placed on the patients acquiring skills during treatment and facilitating its transfer outside the sessions. The clinician is required to have precise practical skills so they can educate the patient to use these skills outside the treatment setting. To make the therapeutic relationship fruitful the use of collaboration is also important. This is seen when the patient brings their understanding of their difficulties and problems, the therapist shares their knowledge of CBT to the patient. As a therapist if you achieve the emotional level of the patients trust (“the therapist knows what he/she is doing,”

“I can trust them”) it could be said that more than half the therapeutic relation is accomplished. With straightforward problems, if the therapist “connects” with the patient is it easy to develop a productive therapeutic coalition within the first 2 sessions. However, with co morbid, complex and personality difficulties to create a productive therapeutic alliance could take up to weeks or months (Kinsella 2008). Once the therapist has made a fruitful therapeutic alliance it could be easier to have an assessment and formulation of the patient.

A way to understand patients and their problems: assessment and formulation

Humans are predisposed to and in a constant process of assessing and appraising events and people in the first few seconds of encounter. Although most assessment takes place in the initial sessions, the process of assessment continues throughout treatment. Cognitive-behavioral assessment strategies take many forms across four domains: cognition, behavior, emotion, and physiology (Blankstein and Segal 2001). Each assessment procedure yields specific information about a particular response system. Assessing a problem with multiple techniques produces a more comprehensive identification of the problem, and gives the therapist a better picture of how well the treatment addresses the problem (Kirk 1989). Cognitive-behavioral assessment often begins with an initial interview (Beck 1995; Blankstein and Segal 2001). During this interview, the therapist clarifies the patient’s problems, formulate the difficulties in manageable units that will encourage the patient to believe that change is possible. Additionally, the assessment process helps the patient learn that variations in the intensity and distress of symptoms are predictable and potentially controllable. The assessment interview also highlights problems that should be prioritized, such as child abuse, suicidal tendencies, or problems with serious physical consequences. The initial interview may be supplemented by a variety of other assessment techniques, including self-report questionnaires, direct observation of behavior, behavioral tests, physiological measures, and self-monitoring. Selfreport questionnaires such as the Beck Depression Inventory (BDI-II; Beck et al 1996) are easily administered and can be collected periodically throughout the therapy process. Moreover, normative data exist for many self-report questionnaires, which can help to contextualize a patient’s score. A particularly useful assessment technique involves the direct observation of behavior. This can be accomplished through frequency counts, duration of symptoms or behaviors, or observations made during role-plays with the patient. Direct observation of the problem behavior can be repeated during the course of treatment to assess change. Specific behavioral tests also provide direct observation of a wide range of problem behaviors. These are indirect, objective measures that are relatively free from observer bias. While such by-products do not focus on the problem behavior itself, they do provide reliable physical evidence that the behavior has occurred.

Formulation involves synthesis of various aspects of client data that provides an explanation of the origins, development and maintenance of the client’s problems. It answers the clients question and provides them with a psychological rational for their problem by answering variants of questions like: ‘Why now?’ ‘Why me?’ ‘How can I get better?’ ‘Why doesn’t the problem just go away?’ (Wills 2008). Formulation further helps the therapist in understanding the client and making treatment decisions (Pearson 1989 and Beck et al 2003) based on scientific evidence, increasing treatment efficacy, making it more individualized and purposeful.

A clinical formulation enables the process of making meaning out of a clients’ experience, while fostering a sense of hope and normalising symptoms. It also aids the mutual understanding and guides the client difficulties. Furthermore, the use of formulation promotes sympathy in the therapist. “What helps the therapist can usually also help the client” (Wills 2008:24). Thus, the formulation facilitates sharing: explicitness and empathy. It makes links between the present and past and helps to expose the underlying processes. Finally, it reveals gaps and missing information. Due to being an active therapy it is useful for the therapist to draw visual diagrams either on a white board or paper so the patient can put jargon words into content.

A strategic posture for help includes: short term, active therapy, problem solving, goal oriented and educational

Cognitive-behavioral intervention occurs over a short term in a time-limited manner. Every attempt is made to effect change rapidly. Many treatment manuals recommend that therapeutic goals be achieved within 12–16 sessions (Chambless et al 1996). The therapist and client address current patterns of thinking and behavior with an eye to enabling the patient to anticipate and navigate similar problems in the future. Treatment is based on present difficulties. Compared to other therapies CBT is not worried with the ways in which the patient’s disorder developed in the past. However it focuses on the factors that the disorder is being effected by at the present time of the treatment (Gelder 2006).

Since CBT is an active therapy it is structured and problem focused. Both the therapist and patient maintain this structure throughout therapy (Westbrook 2008). The sessions are structured via an agenda which contains a mutual agreement between the therapist and patient (Curwen 2000). Besides the first session the layout of the agenda is the same however, the organization of the therapy will be determined by the particular problem the patients’ presents (Curwen 2000). The agenda encompasses several benefits during session. It permits the therapist and patient to use their time most efficiently (Curwen 2000). In addition, it supports teamwork by encouraging a problem solving and business like approach rather than assigning a patient a ‘sick role’ (Curwen 2000).

Having a structure in CBT also helps the patient understand the central themes of CBT and how the individual could use the structure once the therapy is terminated. According to Curwen (2002) a typical structure seen in a session is as follows:

1. Confirm client’s mood.

2. Brief review of week.

3. Set agenda for present session.

4. Feedback and link to, prior session.

5. Review homework.

6. Converse agenda items.

7. Set homework.

8. Inquire about feedback at end of session.

Both parties contribute to the therapy in terms of identifying problems and challenging the negative cognitions that mediate negative emotional states and maladaptive behavior (Beck 1995). The therapist is active across a variety of tasks such a: questioning negative thoughts, teaching new skills, educating about the psychological disorder, modeling new behaviors, and planning homework assignments. In a similar vain, the patient is active: monitoring behavior and thought, completing homework assignments, challenging negative thoughts, practicing skills, etc. The active therapist role is one factor that distinguishes cognitive-behavioral treatments from more traditional forms of psychodynamic and psychoanalytic psychotherapy, which prescribe the therapist to follow the patient’s lead in sessions (Meichenbaum 1995).

As mentioned above the therapy allows helping maintain structure once therapy is terminated it also aids with relapse prevention and it helps by planning obstacles in advance so the patient can overcome the situation outside therapy in “real life” situations.

Furthermore a person’s orientation to his or her problems determines the manner in which a person processes information about the self, the environment, and problematic situations encountered in everyday life. Problem orientation, or attitude toward problem solving, involves the ability to (a) ward off negative emotions (e.g., anxiety, depression, and anger) that hamper problem-solving efforts, (b) promote positive emotions and a sense of competency that facilitate problem solving, and (c) motivate an individual toward solving problems (D’Zurilla & Nezu, 1990; D’Zurilla & Sheedy, 1991; Nezu & D’Zurilla, 1989).

According to D’Zurilla & Goldfried (------), conceptualized problem-solving therapy is a form of self-control training, emphasizing the importance of training the client to function as his /her own therapist. Problem solving refers to an overt or cognitive process that makes available a variety of effective response alternatives for coping with a problem situation and increases the likelihood of selecting the most effective response available. They identified five overlapping stages as representative of the problem-solving process: (1) general orientation or ‘set’ (2) problem definition and formulation (3) generation of alternatives (4) decision making and (5) verification. Training in problem solving involves teaching clients these basic skills and guiding their application in actual problem situations

As mentioned earlier CBT is time-framed therapy therefore, according to Westbrook (2008) to maintain the efficacy as a time limited therapy the agreement to work towards mutually agreed goals in early stages of therapy are important. The patient and therapist set explicit goals for the therapy at the outset of treatment. Typically, the patient will desire a reduction in distressing symptoms. The treatment is tailored to the patient’s specific set of circumstances, such that any number of problems could be targeted for intervention. Goals such as increasing positive experiences, building coping future problems, and prevention of relapse are within the purview of cognitive-behavioral therapies. Goal setting focuses the patient’s thinking upon gains she can achieve through therapy, and can prompt a discussion of the realistic limits of therapy. For example, the goal of ‘never having anxiety again’ is unrealistic, as is the goal of ‘never being sad again.’ Throughout the course of therapy, the patient and therapist can revisit the goals to asses the progress of therapy, revising the goals, if need be, in the face of changing life circumstances.

It is axiomatic within cognitive-behavioral approaches that patients are seen as capable of controlling their own thoughts and actions. Therapy, under this assumption, becomes an educative process aimed at helping the patient acquire skills and knowledge that will enable her to function more adaptively (D’Zurilla and Goldfried 1971). The therapist may instruct the patient throughout treatment for example, regarding the nature and course of the disorder, as well as the rationale behind specific interventions. The educative interaction between the therapist and patient is another factor that sets cognitive-behavioral therapies apart from other schools of therapy (Mahoney1974; Beck et al., 1979 and DeRubeis et al 2001).

CBT is a skills base for implementing strategies; Socratic method, homework bases, self monitoring, self directed, other techniques

In cognitive behvioural therapy, effective interaction between therapist and patient is best accomplished by frequent use guided discovery. The involvement of guided discovery encompasses of asking questions which invite the patient to investigate what she/he is saying and then looking at the situation from a different perspective or “out side the box” this is Socratic Dialogue (Wills 2008). Through this patients are guided through a process of discovering their distorted patterns of thinking and behaving. Is Socratic questioning the therapist barely ever expresses their own judgment but asks questions which make the patient think more deeply (Wills 2008). However, the therapist asks questions that they know the patients will be able to answer. Because CBT is an interactive therapy, according to Wills (2008) during therapy having a list of Socratic questions on hand for both patient and therapist makes therapy more effective.

As skill acquisition requires practice, the patient is encouraged to work on a variety of therapeutic tasks outside of the session. The therapist frames these tasks, or homework assignments, as a vital component of treatment that is crucial to its success (Beck 1995). The therapist and patient formulate the homework assignments together, customizing each task to the patient’s problems and skill set. The therapist clarifies the rationale for each homework assignment and gives specific instructions, allowing the patient to express objections. Whenever possible, the therapist and patient anticipate problems that might hinder completion of the homework task. As homework tasks reinforce and supplement the educational aspects of the therapy, it is important that the patient experiences each assignment as a relative success (Beck et al 1979 and Beck 1995).

Cognitive-behavioral therapy require both patient and therapist to take an active role in the moment-by-moment progress of the treatment. These techniques are seen as self-monitoring which is an important assessment tool. The therapist instructs the patient to observe and record their own behavioral and emotional reactions. Beck (1995) mentions as these reactions are distributed throughout the patient’s daily life, self monitoring tends to be employed as a homework assignment. The therapist and patient collaboratively select the target of monitoring (e.g., a symptom, behavior, or reaction) based upon the patient’s goals and presenting problem list. Self-monitoring serves at least three purposes within a course of CBT: (1) it encourages and effectively trains the patient to observe her own reactions in a more scientific manner; (2) it renders a concrete record of the target symptoms and problems; and (3) new problems can become apparent and targeted for future intervention. Self-monitoring is especially useful in early sessions as a means of assessing the severity or frequency of a particular problem or symptom. However, self-monitoring is equally useful in later sessions as a means of tracking the patient’s progress. Examples of self monitoring include a record of daily activities and corresponding mood; a frequency count of the number of panic attacks per day; a record of the frequency and content of auditory hallucinations; and a food diary in which time, quantity, and type of food eaten are recorded.

Another technique used is problem solving as a self-directed process by which a person attempts to identify or discover effective or adaptive solutions for specific problems encountered in everyday life. According to D’Zurilla and Goldfried (1971) initially, the therapist helps the patient identify and define the problems they face. For each problem, the therapist and patient brainstorm potential solutions, evaluate the quality of each solution, and test out the best solution. Problem solving also entails helping the patient identify and overcome difficulties (practical and cognitive) that he/she might encounter while carrying out the plan. Where testing and evaluation of possible solutions indicates that they are inappropriate, patient and therapist develop either modified or new solutions (D’Zurilla and Nezu 1980; Hawton and Kirk 1989). Problem solving is easily learned and has been applied to a wide range of situations commonly encountered in psychiatric practice: example applications include difficulties associated with mood, anxiety, stress, substance abuse, psychotic symptoms and other health problems (D’Zurilla and Nezu 2001).

Many disorders are characterized by waxing and waning symptomatology.

Preparing clients for the possibility that the problem symptoms will return is, accordingly, an important phase of therapy. CBT gives an emphasis on teaching the patient to become their own therapist (Westbrook 2008). Central to the relapse prevention model is the distinction between a lapse and a relapse. A lapse is defined as a single isolated emergence of a symptom (e.g., a violation of abstinence), while a relapse is defined as a full-blown return of the pretreatment symptom levels (e.g., addictive behavior) (Marlatt and Gordon 1995). A lapse does not inexorably lead to relapse, the therapist and patient can work together to develop skills and strategies to neutralize the lapses that will undoubtedly occur following successful CBT treatment. An equally important application of relapse prevention techniques is to help patients test out whether they have developed realistic expectations of their own ability to cope outside therapy (Young et al 2003), as unrealistic optimism may be a risk factor for relapse (Alvarez-Conrad et al 2002). According to Ellis and Newman (1996), relapse prevention consists of four components: (1) identifying high-risk situations; (2) learning coping skills; (3) practicing coping skills; and (4) creating life-style balance. Following the ethos of relapse prevention, the therapist encourages the patient to frame inevitable setbacks as learning experiences within the therapeutic process rather than as personal failures or treatment failures. Therapists and patients anticipate and identify high-risk situations—those which are most likely to trigger relapse—and rehearse coping strategies that can be used in the event that such circumstances occur. Imaginable techniques, importantly, can be employed: the patient vividly imagines a situation that could trigger relapse, applying the coping strategies to see if they effectively neutralize the advancing dysphoria

DRAWBACKS TO CBT

There is evidence through clinical studies which illustrate the effectiveness and efficacy for the use of CBT in various psychiatric disorders (Dobson 2010). However, significant numbers of patients fail to react sufficiently to mainstream CBT treatment (McKay 2010).

CBT appears to be popular amongst clinical psychologist in the Western culture (Norcross et al 2005) which includes values such as assertiveness, personal independence, verbal ability, logic and behavior change. However, these values may not be celebrated in all cultures. There is a lack of evidence if CBT techniques apply to individuals coming from diverse back grounds including age, ethnicity, race, disabilities and sexual orientation (Dobson 2010). This lack of empirical evidence is critical because it is important for a psychologist to be able to understand the different multicultural facets of the patients to further incorporate in therapy sessions. A meta- analysis by Ghafoori (2004) evaluated if CBT helped children with childhood disruptive behaviours, the results indicated that CBT did help however, Caucasian children significantly from CBT intervention compared to mixed ethnicity group.

As mentioned previously CBT is a popular type of psychological therapy nevertheless this form of therapy may not suit everyone, in other words, ‘one size does not fit all’ (Leahy 2003a). CBT stresses in the significance of structure, empirical evaluation of the patient’s cognitive schemas/core beliefs, direct questioning on the present thinking and goal setting which all sound good (Leahy 2001b) however, it could come across as being overly rigid and mechanistic. Psycho education focuses and emphasices on goal setting which may prevent exploration of the larger picture of the individual such as, relationship, family origin, and culture. Sometimes CBT may be viewed as being too superficial and overlooking the importance of the patient’s past.

When individuals go for therapy they are under the impression the therapist is going to sort out their problem however in CBT this is not the case-the patient cannot have a passive role (Kinsella 2008). Not being able to play a passive role in therapy can cause a lot of unease for the patient. For example, those who have low self esteem could feel anxious with an agenda (Kinsella 2008). Further, Kinsella (2008) mentions patient could feel as though they are being ‘tested’ with questions by the therapist resulting in feeling foolish. Those patients who are interpersonally sensitive might believe others are trying to humiliate them. CBT is very direct and ‘to the point’ which does not work with all patients and being a CBT therapist it is important to hold back and not over power the patient (Wills 2008). If the therapist does not restrain from being persuasive the patient could feel overwhelmed (Heesacker & Meija- Millan 1996) and this could lead to feelings of resistance from the patient. Therefore it is better not to be influential, rather use guided discovery when helping a patient to open up during therapy.

As mentioned prior the therapeutic relationship is a robust predictor of positive outcomes for the patient and therapist (McKay 2010). Evidence in psychological research shows that there is usually a negative outcome in which is affected by the way the therapist approaches the patient and the attitude the patient feels from the therapist (McKay 2010). Data seen in several disorders such as bulimia nervosa (Loeb et al 2005), OCD (Hadley 1976) and social anxiety disorder (Hayes et al 2007) that a poor therapeutic alliance in CBT showed adverse effects. The emphasis of emotion is a vast aspect in CBT nevertheless it easy for a CBT therapist to drift into premature closure of emotions (Wills 2008) due to being goal focused and structured. According to McKay (2010) the course of treatment is heavily dependent on if the patient is comfortable with the therapist by trusting them.

Another roadblock seen in CBT is that it requires fully developed cognitive skills to understand the verbal information conveyed in therapy. According to McKay (2010) the information in therapy helps in modifying behavior and emotions of the patient. Thus this eliminates many people with developmental disabilities and children. Studies by Doubleday et al (2002) have moderately supported what McKay (2010) had mentioned. Their sample was collected on older adults suffering from depression and anxiety who were under CBT. Results from this study showed there was improvement in individuals with higher intelligence.

Clinical evidence suggests that short-term treatment in CBT is as effective as medication especially with anxiety disorders and mild to moderate depression (Bhupa 2009). However being a short term therapy CBT will curtail individual suffering from other psychological disorders. A study by Howards et al (1985) illustrated that the length of the treatment generally showed a positive relationship with outcome in therapy. Therefore the impact of sessions is import as many psychologists believe those individuals would benefit from another full course of CBT or extra sessions (McKay 2010).

CBT is intended at changing the content of negative automatic thoughts and beliefs about the world, self and the future, rather than processes involving the maintenance for disorders such as rumination. This limitation in CBT treatment, could account for why depressed patients are exposed to relapse following treatment termination. Residual depression is considered to be one of the symptoms remaining after partial and full rumination from depression (Riso et al 2003).

In any psychological therapy, motivation of the client is very important because this makes therapy more effective. However in CBT it is assumed that patients are motivated and willing to change challenging thoughts and behaviours (McKey 2010). This stratagem would be ideal for individuals who are ready for the change nevertheless what happenes to those who are not? Patients are not only ready for change but could be scared about the change or may believe their symptoms are valuable (McKey 2010). According to Borkove (1995) research illustrated significant amount of patients with generalized anxiety disorder viewed their worries as adaptive. This is similar to patients with anorexia nervosa who often view their symptoms as highly egosyntonic and as an essential aspects of their individuality (Vitousek 1998).

Homework is seen as one of the key elements of CBT and the completion of homework is coupled to success (Garland et al 2002) in therapy. However homework also demonstrates the most difficulties in CBT. According to Burns (1999) home work has a limited feature in CBT because patients can forget to do it, not understand the work, it can be frightening for patients, sometimes the term home work can bring up difficult memories and some patients might have difficulties with concentration and therefore completing the home work, etc. this could lead to a blockade in the therapeutic relationship between patient and therapist.

CONCLUSION

Cognitive Behavioural Therapy has flourished in a short period of time becoming a fashionable form of psychotherapies (Clark 1997) in most Western countries especially, the United States being its birthplace. Even though, CBT rooted from the United States it has developed strongly in the United Kingdom. In the U.K. there is a great demand for cognitive therapy along with research on its treatment and the British Association for Behavioural and Cognitive Psychotherapies (BABCP) has maintained good practice which is recognized internationally (Sanders 2005). According to Lam (2008) modern CBT has still kept its ancestry in a standardized and non-pathological method to emotional troubles. CBT was conducted in helping mental health problems by psychiatrists, psychologists and nurses. Nevertheless CBT is also being used in other professions such as psychotherapists, social workers, probation workers and counsellors (Sanders 2005). There is substantial empirical support for the effectiveness of CBT in a variety of mental disorders. According to the National Institute for Clinical Excellence (----) CBT should be available for patients with schizophrenia, depression, generalized anxiety and panic, eating disorders and post-traumatic stress disorders.

There are numerous reasons why CBT does work for many patients and most of them point towards the fact that it is not the patient at fault but it is the therapy or the treatment which is not of much benefit to the client (Hollon 2010). Lack of response from the client could be caused by the inability of the client/patient to follow up with the therapy. However if the therapy is sound and has its uses then it finds ways of evolving to suit the needs of the clients. The research and development in the field of CBT is aiming to custom-make treatments and integrate the therapy with other known therapies, especially for the more challenging cases (McKey 2010). It is the collaborative approach which is the essence of therapy. The notion “one size fits all” is passé and each therapeutic input is unique. The sooner the clinicians accept this the higher the chances of CBT benefiting a large proportion of the population in question.

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