A brief history of CBT : Prof. Beck to the rescue...
CBT, also known as Cognitive Therapy (CT), was developed by an American psychiatrist, Aaron T Beck, back in the 1950s. At that time he was engaged in psychoanalysis and was frustrated at his results, or the lack of them, with that type of therapy. Some of us would say that things haven't changed much in psychoanalysis over the years since then.
Anyway, he wondered if there might be a better way of treating mentally ill patients.
In his book, Cognitive Therapy and the Emotional Disorders, he describes the early observations which led to one of the most powerful anti-depressant tools ever discovered. Briefly, he discovered the phenomenon known as the negative automatic thought but there was a lot more to his early work.
As he continued working on his new therapy, he took on patients others had rejected as hopeless. Dr Beck, said his colleagues, these people have no motivation. How can you hope to work with them?
His reply was that it was his job to help those patients find the motivation to become partners in therapy with him.
From those early beginnings, CBT has grown and grown. Beck's initial approach has been maintained; that of scientific enquiry, of rigorous testing of hypotheses, of detailed clinical research, of constant questioning of theory and method and results, above all a steady focus on the questions every patient wants answered---will this help me get better?
It is now one of the best-researched treatments in the world and that message has finally permeated both those bodies which advise on NHS treatment (particularly NICE) and those holding the purse-strings (particularly the Treasury).
End result? The UK government recently committed over 300 million pounds over three years to fund a massive expansion of CBT training and services.
But was he the first?
Actually, no. He wasn't the first to write down the vital principles of CBT although he did it in such a way that the whole world was able to learn from his work. He also worked in a spirit of scientific enquiry which was probably just as valuable as what he published and finally he got us working in a true collaborative partnership with our patients.
I call CBT the codification of common sense.
I call CBT the instruction manual for living a well-balanced life. You all know people who cope extremely well with life's disasters and annoyances without being totally bland or blasé about it? People who are good human beings, who are in tune with their emotions but not overcome by them?
Chances are those people are using CBT tools on themselves without even realising it.
Anyway, the history of CBT probably starts with the Stoic philosophers. Epictetus is much-quoted.
He said, "Men are not moved by things but the views which they take of them.”
Think about that for a minute.
He was heavily influenced by Socrates, of whom more anon. In turn Epictetus was a major influence on Marcus Aurelius, another Stoic, whose Meditations are worth a read.
Marcus said, "If thou are pained by any external thing, it is not this thing that disturbs thee, but thine own judgment about it. And it is in thy power to wipe out this judgment now.”
Think about that for a minute.
Think about the last event or exchange which really upset you.
Was it the event?
Or was it the thoughts and emotions you felt in response to that event?
And what was in your mind to make you have those thoughts and emotions?
Think about this scenario
Two different men in their cars. Going home. Caught in traffic.
One gets really upset or angry or worried or annoyed.
The other tunes in a radio station with some good music or puts on a CD, sits back and relaxes.
What is the difference?
Which one would you prefer to be?
Given that no amount of rage will clear the traffic jam?
And what would you have to do to react the way you would prefer to react?
Do some thinking on this, please, preferably with pen and paper.
Introducing some important concepts
We often talk about collaborative working in CBT but what is it? Is it just another buzz phrase or does it mean something?
Actually, it means a lot. It is a key feature of CBT and without it, the therapy simply does not work well. It is said that in a good therapy session you should see two people working intensely and actively together and that it should be impossible to tell who is who just from looking at the scene.
It's not just a therapist being nice, empathic or understanding; it's not about walking in the patient's shoes and seeing his world from the inside. Those characteristics are all important but good collaboration is more about two people working on a problem.
The patient brings the raw data; remember the patient is the expert on his problem.
The therapist brings tools, structure, and an effective way of working... which leads nicely on to one of the most important tools in the CBT armoury---Socratic dialogue.
Socrates said he could not make a man do anything, he could only teach a man to think. He was inspired by his stone mason father and his midwife mother to describe himself as a "midwife of ideas" who helps people bring forth that which is within.
Socratic dialogue is vital for good CBT; it is one of the essential tools for helping patients find their own answers to their own problems.
What is it though?
Well it has four stages;
- Asking informational questions,
- Active empathic listening,
- Summarising a lot,
- Asking synthesising or analytic questions.
It has to be underpinned with a genuine interest in the person and his situation, a naive curiosity, making as few assumptions as humanly possible, asking questions because you actually want to hear the answer.
The best one-line definition I have ever heard is "the fine art of holding back." Having done some basic CBT with patients, I can attest to the enormous value of asking questions and holding back from making assumptions or trying to guide the patient towards what I think is the answer.
This is of great value for moderate to severe depression in the early stages of treatment. Simply put, it is about helping patients do something; get out of the house, go for a coffee, meet a friend, whatever. It involves preparation and planning and problem-solving in advance, it involves a review of the activity and learning from that, then planning a bit more activity next time. If it sounds easy, it's not! However, It is very effective and some studies show it is the most powerful initial treatment for depression.
Negative automatic thoughts (NATs)
Professor Beck made many observations of these in his psychoanalytical practice. Basically these are extremely self-critical thoughts the patient has about himself; they are brief and apparently fleeting and very frequent, occurring perhaps hundreds of times a day.
Without going too deeply into what is a moderately advanced CBT technique, we generally find that depressed patients have a lot of very extreme NATs. They are a function of distorted thinking styles, they are a product of abnormal cognitive development and they are associated with mood dips. Get enough mood dips and you don't even notice the better bits in between. It all seems bad.
A key principle in CBT is that these NATs can be spotted with a bit of tuition and practice, and they can then be challenged in a very logical way. A successful challenge results in mood improvement.
To give an example of how well this technique works, at this stage I spot and challenge my own NATs almost without noticing. I maybe realise afterwards what I just did.