This paper looks to explore and critically review the main theories which include behavioural and cognitive theories that underpin Cognitive Behavioural Therapy (CBT), their influence in the development and evolvement of CBT and how they have expanded to inform assessments for children and young people.
The Behaviourist movement began in 1913 with John Watson challenging the introspections approach and promoting the study of observable behaviour/actions. His manifesto ‘Psychology as the Behaviourist Views It’ introduced a number of principles regarding methodology and behavioural analysis; All behaviour is learned from the environment, psychology should be seen as a science with theories supported by empirical data collated through controlled observation and measurement of behaviour as well as to measure and study observable behaviour, as opposed to internal processes such as thinking and emotion. It states there is little difference between learning that takes place in humans and that in other animals and that behaviour is the result of stimulus-response. This Methodological behaviourist approach to learning is based on the notion that the mind is tabula rasa (a blank slate) at birth and learning evolves through nurture and conditioning. (McLeod, 2017).
It was Pavlovs experiments of dogs conditioned reflexes in 1927 that introduced the theory of classical conditioning. Behavioural experiments were conducted observing and measuring dogs unconditioned and conditioned responses to either conditioned or unconditioned stimuli. Learning was demonstrated through the use of conditioning, the formation of connections or associations between stimuli, suggesting that response is learned and repeated through immediate association whether this is a desirable or undesirable response (Gross, 2009) In relation to human behaviour, the premise is that all behaviour is learned and maladaptive learning can take place leading to ‘abnormal behaviour’ and phobias. Thus, if it can be learnt it can be unlearnt. In particular specific anxiety phobias can be linked with conditioning behaviours. (William & Darity 2008).
Mowrer (1939), building on the writings of Pavlov, stated that ‘anxiety is therefore a learned response, occurring to signals (conditioned stimuli) that are premonitory of (i.e. have in the past been followed by) situations of injury or pain (unconditioned stimuli)’.
It was Watson who was the first psychologist to apply the principles of classical conditioning to human behaviour. This was done through The Little Albert experiment (Watson and Rayner 1920), where a conditioned fear response of rats was developed within a young child. This experiment demonstrated the conditioning of fear acquisition.
Following on form these theories, it was Wolpe (1958) who introduced Systematic Desensitisation, based on the principle of counter-conditioning and reciprocal inhibition. ‘If a response inhibitory of anxiety can be made to occur in the presence of anxiety-provoking stimuli it will weaken the bond between these stimuli and the anxiety’ (Wolpe 1969: Gross P.820). Thus being in a relaxed state when exposed to or imagining the feared object/situation coupled with the implementation of habituation will begin to extinguish the conditioned response. This treatment is particularly effective for specific phobias. However, it may be limited if some patients have difficulty in transitioning from using imagery to real-life. Wilson and Davison (1971) debate that relaxation might just be a useful way of encouraging the person to confront their fears and also Marks (1973), states that it is the exposure to the feared situation that is the most effective form of treatment and learning rather than the relaxation apsect. The theory also builds on Mowrer, (1939) that fear can form motivating properties and that reducing fears can reinforce behaviours such as avoidance and these can build in strength. From a practical point of view this theory underlies the thinking associated with those forms of behaviour therapy that deal with fear reduction by breaking the links between stimulus and undesired response i.e. desentisation and flooding (Wolpe, 1958, Eysenck & Rachman, 1965; Rimm & Masters, 1974).
Rachman (1976) theory of Fear Acquisition, ‘assumes that fears are acquired and that the process of acquisition is a form of conditioning’. Fears can be developed via three routes; conditioning, vicarious exposures and by information and instruction. In contrast to classical conditioning, fears can develop without direct contact with fear stimuli but through either vicarious exposure or information transmission. However, increasing the strength of a fear depends on the number of repetitions of the association between pain/fear experience and stimuli as well as the intensity of the fear that is experienced.
However, these approaches do not necessarily explore that most people will experience a range of fear-provoking situations but can remain fairly fearless. Also, it is worth considering that these theories support fears that arise in an acute manner, however, more difficult when the onset is uncertain Goorney and O’Connor (1971). Marks (1969), claims that fears that develop gradually (e.g. social fears) and cannot be related to a specific circumstance can be an issue for this approach.
Edward Thorndike’s (1905), Theory of Law of Effect led to the development of the next phase of Behaviourism providing the notion of operant behaviour. Thorndike (1898) studied learning in animals (ie. Puzzle boxes for cats to escape from) to provide empirical evidence to support his theory. The experiments led to his proposition that any behaviour that is followed by pleasant consequences is likely to be repeated and any behaviour followed by undesirable consequences is likely to cease (Operant Conditioning).
Burrhus Skinner (1936), building on Thorndike’s theory, began to make the distinction between respondent and operant behaviour. Skinner began to question the theory of classical conditioning, claiming that most animal and human behaviour is not triggered by specific stimuli, but more as result of how they operate in their environment and how this behaviour is key in determining certain consequences. He claims that the learner is far more active than Pavlov or Watson would recognise. (Gross, 2005 P.178).
Skinner (1948) studied operant conditioning by conducting experiments using rats or pigeons placed in a ‘Skinner Box’ (a form of puzzle box), to explore how operants (intentional actions) have an effect on the surrounding environment and identify the processes which made certain operant behaviours more or less likely to occur. Skinner concluded that operant conditioning uses reinforcement and punishment systematically to facilitate learning (William & Darity, 2008). If behaviour is not supported by reinforcement then it becomes extinct.
This was a move from the classical conditioning perspective, which just focused on antecedants and reflexes, by emphasising the influence of reinforcers (positive – rewards and negative – removal of negative stimuli) to increase and strengthen behaviour and punishment to reduce and weaken behaviour.
Skinner adapted and developed this theory to demonstrate the effectiveness, speed of learning and extinction of certain behaviours. Introducing the idea of behaviour shaping through successive approximation (a series of rewards that provide positive reinforcement for behaviour change). Bringing this theory into therapy, allows us to understand the key operants that are maintaining maladaptive behaviours e.g. most anxiety disorders are reinforced by negative reinforcement such as avoidance. This can be effectively applied, especially in children and young people where we are able to moderate and shape behaviour by using positive reinforcement (praise and rewards).
Although, Skinners theory can explain a range of behaviours and the process of learning, it fails to take into account inherited and cognitive factors in learning.
However, in contrast, Hull (1943) introduced Drive-Reduction Theory, which sought to demonstrate that behaviour and learning was developed through motivation and behaviour. For example an imbalance will create a need, which in turn creates motivation and drive, concluding that behaviour can be recognised as an attempt to reduce the drive and meet the need. Therefore, the association of stimulus and response in classical and operant conditioning only results in learning if accompanied by a drive reduction (Ed Jacqueline et al).
In 1963 Albert Bandura introduced a more sophisticated model of learning – Social Learning Theory.
Bandura’s theory explains that learning occurs in a social context and that children and adults learn through imitation and observation of consequences (Vicarious Learning). Behaviour that is rewarded is more readily imitated than behaviour that is punished, which was illustrated during his Bobo Doll experiment in 1961 (Ed. Jacqueline et al),. Children are surrounded by a various models i.e. parents, peers, teachers etc who provide examples of how to behave in certain situations and observe the consequences of this behaviour and begin to internalise this learning. A child will start to imitate behaviour if they believe it will be positively reinforced. Another factor influencing the level of imitation in behaviour is if the child perceives the ‘model’ as similar to themselves i.e. same gender.
However, it is important to bear in mind that positive or negative reinforcement will have little impact if the reinforcement offered externally does not match with an individuals needs. (SMcLeod, 2016).
Bandura Social Learning Theory presents four meditational processes: Attention which refers to the level of exposure to a behaviour and how much it is noticed, Retention, how well the behaviour is remembered as much of social learning is not immediate, Reproduction the ability to perform the behaviour and finally Motivation, the rewards and punishment that follow the behaviour. Unlike previous theories, Bandura’s Social Learning approach began to recognise the thought processes that occur when deciding whether or not to perform a particular behaviour.
McLeod (2016) offers some criticisms to Social Learning Theory as describing human behaviour as complex and that behaviour is more likely to occur through an interaction between nature and nurture rather than just solely on the environment. Also social learning theory cannot explain all of behaviour especially in the case of an absence of an apparent model in a persons life were they are able to imitate certain behaviours.
Overall there are strengths in behaviourist approaches as they provide empirically based evidence of learnt behaviours via stimulus and can be related into therapeutic practice in particular addressing behavioural difficulties and modification, specific phobias, OCD and other anxiety/fear based disorders.
However, behaviourism only really provides a partial explanation of human behaviour.
Although providing a science based viewpoint, comparing animal to human behaviour is limiting, we cannot apply the basic principles of learning equally to all species (Seligman, 1970). Weiskrantz, (1982) stated that classically conditioned responses in humans extinguish more rapidly because they are modulated by more complex human memories. (References on Gross P.181). Thus behaviour is measured objectively and therefore does not consider the impact of the complexity of cognitions or emotions.
Carl Rogers from a Humanists viewpoint claims that the scientific experiments used to control variables create an artificial environment and has low ecological validity. Also need to consider free will in decision making (McLeod, 2016)
Freud’s psychodynamic approach adds that ‘behaviourism does not take into account the unconscious mind and its influence on behaviour and that people are born with instincts rather than a blank slate’. It is also important to consider he role of nature and biology in influencing behaviour for example, fluctuations in hormones (McLeod, 2016).
Furthermore, recognising that Social Learning Theory did not adequately account for how we develop a whole range of behaviours including thoughts and feelings, knowledge, concepts and abstract rules. In response to this Bandura (1986) to develop Social Cognitive Therapy, which incorporated these factors.
However, it was Bandura’s Social Learning Theory in 1963 which formed the bridge from a behaviouralist approach to learning to a more cognitive one.
Cognitive Theory
Cognitive Psychology grew in popularity during the mid-1950’s, due to the dissatisfaction of the behaviourist approach focusing on external behaviour rather than internal information processing.
“Outcome studies of Behavioural Therapy showed considerable effectiveness in the treatment of phobias and obsessive compulsive disorders, however, this therapy became too limited in its framework and range of problems for which it was effective”. (Rachman, 1977: Oxford P.3)
For example Grant et al (2007) states that the role of cognitive factors of behavioural change e.g. covert behaviour such as obsessional thought or observational learning could not be directly addressed by behavioural methods alone.
Cognitive learning is defined as learning that is concerned with acquiring problem-solving abilities through conscious thought (Longe, 2016). Thus, Cognitive Theory looks at how an individuals intelligence and acquisition of information from their environment affect their behaviour.
Albert Ellis’s publication of Reason and Emotion in Psychotherapy in 1962 gave the emphasis on the primacy of cognition. Ellis asserted the notion that people are disturbed not by events themselves but by their perception of them. Through his Rational Emotive Behaviour Therapy (REBT), Ellis claimed that irrational thoughts are the main cause of all types of emotional distress and behaviour disorders. (Gross, 2005 P.826). According to Ellis the aim is to replace these irrational beliefs with more reasonable ones.
Meichenbaum in 1977 built on this theory, by explaining that neurotic behaviour is due to ‘faulty internal dialogues’ and therefore, by training to self-instruct successfully when experiencing these challenging thoughts would reduce the behaviour. Wolpe (1978) argued that this particular Self-Instructional technique isn’t as effective for severe anxiety, because many neurotic fears are triggered by objects and situations which the patient understands are harmless and that the fear is irrational (Gross, 2005 P. 826).
Beck in 1976 introduced the Cognitive Model of Emotional Disorders, which proposes that distorted or dysfunctional thinking is common to all psychological disturbances. However, it is widely agreed that Becks publication of Cognitive Therapy for Depression in 1979 was the most influential cognitive models that fuelled the revolution. Beck claimed that depressed individuals feel the way they do because their thinking is dominated by negative schemas and these are fuelled by certain cognitive biases, which cause the person to mis-perceive reality (Gross, 2005). P.826.
However, Champion and Power, 1995 criticise Becks model as they believe it underemphasises social factors. Gross (2005) p. 827 states that Freud also perceived peoples feelings as being the dominant part of the ego and affecting our thoughts, whereas Becks considers that it is our thoughts that effect our feelings. Gross (2005) also explains that there is a challenge to prove that the thoughts are the cause of depression because also manipulating people’s emotions can also change their thinking.
Beck, however, recognised the value of behaviour therapy’s emphasis on scientific method, empirical research and verifiable evidence (Bennett-Levy et al, 2004) as well as the current maintaining factors rather than past causes, understanding that behaviour change is also a means of cognitive and affective change.
It is here that we began to see the emergence of CBT. Westbrook et al 2011, describes CBT as the formation of several principles; collaborative empiricism, the combination of both behaviourism and cognitive theory, the Here and Now principle as well as recognising the interacting systems that occur between the environment, thoughts, feelings, behaviour and physiology.
Due to the scientific and robust evidence base that both behavioural and cognitive theories provide, Cognitive Behavioural Therapy is recommended by NICE (National Institute of Health and Care Excellence) as the first line of intervention for Depression and Anxiety for children and young people.
However, here is now an emerging new wave of CBT such as Mindfulness, Acceptance and Commitment Therapy and Dialectical Behaviour Therapy, which build on Behaviour and Cognitive approaches but with an emphasis on emotions and increasing the acceptance of an individuals internal experiences rather than going against them (Hayes, 2004). Although these interventions are still in their infancy, DBT and Mindfulness already have a strong evidence base for their clinical effectiveness, however, their application to mental health problems is still in the early stages of investigation. (Grantham & Cowtan, 2015).
CBT Assessment
How do such theories then inform CBT Assessments and which theories and models provide the most robust way of assessing a persons problems in a CBT focused way.
CBT assessment will take various forms in order to identify behaviour, cognition, emotion and physiology about an individual and their particular response system e.g. interviews, observations and standardised measures.
Kirk, 1989 (Paul Grant, Paula et al), therefore states that ‘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 can address the problem’.
Thus, the aim of assessment according to Westbrook et al (2011) is to arrive at a formulation, by repeatedly building and testing hypotheses and what process might be important to the formulation. With the purpose of encouraging change through goal setting.
Within the CYP IAPT Principles as set out in the ‘Delivering Well and Delivery Well’ document (CYPIAPT In CAMHS Values and Standards, 2014), it is important that CBT assessment promote collaborative practice, joint decision-making, the use of Routine Outcome Measures and evidence-based practice.
Initially within any assessment we would be gathering information from the client in order to then analyse the problem using various cognitive and behavioural tools. CBT models can often provide a form of psycho-education and ways in which an individual can begin to develop awareness and understanding of their internal processes.
The use of Routine Outcome Measures, in assessment help to improve clinical practice and outcomes.
The Parent and Child Revised Child Anxiety Depression Scale (RCADS) are standardised scales which are evidence based (Chorpita et al, 2000). Informed primarily from cognitive and behavioural theories their function is to collate information on presenting symptoms and thoughts, feelings, behaviours and physiology and measures the frequency of these to help identify anxiety disorders and low-mood. Miller and Duncan (2000) developed a brief Outcome Rating Scale to illicit feedback on functioning, again a tool which creates an opportunity to explore further negative cognitions or behaviours that are impacting on the young persons day to day functioning.
At the information gathering stage we would be focused on ascertaining a range of variables that affect the individual; situational, behavioural, affective, physiological, cognitive, social/interpersonal, the consequence and impact of the behaviour, possible coping strategies, maintaining processes and behaviours. It is important to also assess vulnerability factors, levels of risk, precipitating and modifying factors, frequency of the problem, intensity and severity, number of times the problem occurs and duration. In addition discuss confidentiality and consent with the young person (Westbrook et al, 2011).
CBT assessment draws on various models and frameworks provided by behavioural and cognitive theories as useful tools to help navigate through the assessment process in order to gather the key information on these intricate variables to help inform formulation.
Carr 2006 offers a useful longitudinal assessment and formulation tool (5P’s) in order to begin to gather relevant information; Predisposing factors which are any factors that have contributed to the persons vulnerability to their current problem, Precipitating factors which cause the onset of the problem; Presenting factors a description of the persons current difficulties including risk assessment, Perpetuating factors which maintain the current difficulties and Protective factors which prevent or lessen a particular behaviour or the problem e.g. the clients resilience and family network.
This is a framework which provides the opportunity to integrate both behavioural and cognitive assessment for example, during the exploration of precipitating factors, pre-existing beliefs may present themselves and within Presenting factors, you are able to define thoughts, feelings, behaviours and physiology as well as identifying any maintaining cognitions or behaviours.
Skinner used the term Behaviour Analysis in order to focus on identifying target behaviours, thus it is important that we are able recognise the cause or the function of the unhelpful behaviour.
One tool that evolved from this theory and can be applied to behaviour analysis is the Functional Analysis model for examining the relationship between behaviour and the environment. It is a scientific approach and information can be gathered from a variety of sources via behavioural observations, behavioural measures (i.e. Becks Depression Inventory, 1996) and self-monitoring activity diaries. Functional Analysis is not a ‘method’, but it is one possible product of the application of behavioural assessment (Haynes & O’Brien 1990). Functional Analysis is also termed ‘A-B-C Analysis’ as it aims to identify three main components; Antecedents, Behaviour and Consequences and forms hypotheses of their inter-relationships (Yoman, 2008). Skinner claimed that all behaviour can be broken down into these three components to identify the function that the problem behaviour serves.
Questions that would be used in order to identify these three components would be for example: What are the triggers to the problem, what physical symptoms are present? What does the person do e.g. avoidance, safety behaviours, escape? What happens afterwards? What is the impact and consequence of this behaviour? What makes the problem better or worse?
However, using this as stand alone tool in assessment, is limited as it focuses on the behaviour and does not allow the therapist and client to explore cognitions. Thus integrating Ellis (1957) ABC Technique of Irrational Beliefs three stage model (Activating Event, Beliefs and Consequences of the negative beliefs) would help provide a much richer picture of the clients problems and maintaining beliefs and behaviours. (McLeod 2015).
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