8.2 Cognitive behavioural therapies

Behaviour therapy

Functional analysis

Behaviour therapy changes observable behaviour through learning principles.

• Functional analysis maps antecedents, behaviour and consequences: what happens before, what the person does and what follows.

• Acquisition differs from maintenance: a frightening encounter may condition fear of dogs, and avoiding dogs then relieves anxiety and maintains the avoidance.

• Similar behaviours can serve different functions, so checking maintained by anxiety relief needs a different plan from checking maintained by attention.

Operant conditioning

"Positive" means adding a stimulus and "negative" means removing one. Reinforcement makes a behaviour more frequent and punishment makes it less frequent.

• Compulsive rituals in obsessive-compulsive disorder (OCD) are maintained by negative reinforcement: the ritual removes anxiety, so it is strengthened and more likely to recur.

• Negative reinforcement is not punishment, because it makes the behaviour more frequent.

• Punishment may suppress behaviour without teaching an alternative, so reinforcement-led approaches are preferred in intellectual disability and dementia care.

• Extinction removes the reinforcer that maintains a behaviour, and an extinction burst is a temporary increase in the behaviour after reinforcement stops.

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Schedules of reinforcement

Building new behaviour

• Shaping builds a behaviour absent from the repertoire by reinforcing successively closer approximations, raising the criterion for reward step by step.

• The Premack principle uses a high-probability behaviour, a frequent and preferred activity, as the reinforcer for a low-probability one.

• Discrimination learning is learning to respond differently to different cues, and the cue that signals reward is the discriminative stimulus.

Social learning

• Bandura's social learning theory holds that people acquire new behaviour by observing and imitating models without being directly reinforced, unlike operant or classical conditioning.

• Social skills training teaches a specific skill through instruction, modelling, role play, feedback and real-world practice in varied settings.

Systematic desensitisation

• Reciprocal inhibition, Wolpe's principle, holds that a response incompatible with anxiety, such as relaxation, suppresses anxiety when it is evoked together with the feared stimulus.

• Systematic desensitisation rests on reciprocal inhibition and is the behavioural treatment matched to a specific phobia.

It runs in three stages:

1. The patient first learns relaxation.

2. Patient and therapist then build a fear hierarchy.

3. The patient works through graded exposure from the bottom of the hierarchy upwards while relaxed.

Exposure and flooding

• Flooding is prolonged, intense, in vivo exposure to the most feared stimulus, with escape prevented until anxiety falls through habituation.

• Flooding differs from systematic desensitisation in having no graded steps and no relaxation.

• Inhibitory learning is a contemporary account in which exposure builds a new association that competes with the old fear, so distress need not fall within a session.

• In contemporary exposure, relaxation kept during the task can become a safety behaviour.

• Exposure and response prevention in OCD combines contact with triggers and resisting compulsions, such as touching a feared door handle without washing.

Other behavioural techniques

• Activity scheduling and graded task assignment are behavioural techniques of cognitive behavioural therapy (CBT): they act on what the patient does, not on appraisals and beliefs.

Behavioural activation

• Behavioural activation is a behavioural therapy whose main indication is depression.

• It rests on a reinforcement model in which withdrawal and avoidance maintain low mood.

• Its functional analysis examines how situations, the patient's responses and their consequences link together to trigger and maintain low mood.

• Assessment maps each episode as TRAP (trigger, response, avoidance pattern) to build an alternative coping response (TRAC).

• Rumination is formulated as avoidance and judged by its function.

Pacing in chronic fatigue

• Pacing in myalgic encephalomyelitis or chronic fatigue syndrome (ME/CFS) splits symptom-provoking activity into shorter parts with planned rest, so that effort stays within the person's energy limit.

• Graded exercise therapy differs in raising activity in fixed increments.

Cognitive therapy

Beck's cognitive model

Aaron Beck originated cognitive therapy. Its features are the negative cognitive triad, automatic thoughts, collaborative testing of evidence and a structured agenda.

The model links a situation to the person's interpretation, feelings, physical responses and behaviour, and each can change the others.

Levels of belief

• Compensatory strategies keep the core belief untested, because someone who always pleases others never learns whether they would be accepted without it.

• Schemas bias attention, memory and interpretation, so work on automatic thoughts alone may leave them unchanged.

Beck's cognitive therapy has four processes:

1. The therapist elicits the patient's automatic thoughts.

2. Therapist and patient test those thoughts.

3. They identify the maladaptive assumptions beneath the thoughts.

4. They test those assumptions.

The therapeutic stance

• Collaborative empiricism means therapist and patient jointly test thoughts and beliefs as hypotheses, aiming at accurate appraisal rather than forced optimism or reassurance.

• Guided discovery leads patients to reach their own conclusions.

• Socratic questioning explores evidence and alternatives: "What supports that thought? What does not? What else could explain it?"

• Cognitive therapy has the patient test their own thoughts, unlike transference interpretation, direct disputation of irrational beliefs in Ellis's rational emotive behaviour therapy (REBT), or skills training in dialectical behaviour therapy (DBT).

• A structured session has a mood check, an agreed agenda, homework review, focused work and a new between-session task.

Cognitive distortions

Cognitive distortions are Beck's systematic errors in appraising events, found in automatic thoughts. They are a separate category from psychoanalytic defences, formal thought disorder and repetitive thinking processes.

• Selective abstraction starts from one real detail, whereas arbitrary inference has no evidence behind it.

• Overgeneralisation turns isolated incidents into a wide rule, whereas selective abstraction judges a single experience by one detail.

Techniques

• In cognitive behavioural therapy (CBT), cognitive methods act on the content of thoughts, such as decatastrophising, and behavioural methods act on what the person does or on arousal.

• A thought record weighs existing evidence for a thought, whereas a behavioural experiment tests a stated prediction against new observations.

• Safety behaviours are identified before an experiment, because a person who credits them with preventing disaster keeps the feared belief.

• Activity scheduling has patients plan activities rather than wait for motivation, then rate pleasure and mastery, breaking the cycle of withdrawal and low mood.

• Behavioural activation was developed as a standalone treatment for depression by Christopher Martell, with Michael Addis and Neil Jacobson.

• Exposure and response prevention, central to CBT for obsessive-compulsive disorder (OCD), means facing triggers while resisting compulsions.

• Paradoxical injunction, prescribing the unwanted symptom, is a high-risk method borrowed from strategic and systemic therapy and is rarely used in CBT.

Content specificity

Beck's content-specificity hypothesis holds that each disorder has its own characteristic cognitive content, so a described pattern of thinking identifies the disorder.

• The reformulated learned helplessness model gives depression an attributional style of internal, stable and global explanations for negative events.

Disorder-specific models

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• In the Ehlers and Clark model of post-traumatic stress disorder, active thought suppression maintains symptoms by causing rebound, and suppression also keeps obsessions going in OCD.

Applications

• Health anxiety: CBT for hypochondriasis aims at a realistic change in how threatening illness-related thoughts and interpretations are held, not at eliminating them or at certainty of good health.

• Psychosis: CBT aims to reduce distress linked to symptoms and improve functioning, partly by re-evaluating maladaptive coping responses, rather than to remove symptoms.

Turkington's elements of CBT for psychosis are:

• The therapist builds a therapeutic alliance.

• Therapy supports medication adherence.

• Therapy offers normalising explanations.

• Therapy works to decrease the impact of positive symptoms.

• Graded reality testing starts at the periphery of a belief and works inwards, rather than challenging the core delusion directly early on.

Relaxation, assertiveness and relapse prevention

Choosing the technique

• Choose the technique from the problem maintaining the difficulty, not from the diagnosis alone.

• Relaxation suits troublesome arousal, assertiveness training suits difficulty expressing needs, and relapse prevention prepares for the high-risk situations that recur after improvement.

Relaxation methods

• Öst's sequence runs through full muscle relaxation, release-only, cue-controlled and differential relaxation, ending in rapid relaxation within 20 to 30 seconds.

• The patient practises sitting, standing and moving, with regular homework, before using the skill in anxiety-provoking situations.

Indications and limits of relaxation

• NICE (the National Institute for Health and Care Excellence) lists applied relaxation alongside cognitive behavioural therapy as a high-intensity option for generalised anxiety disorder.

• It is offered when lower-intensity treatment has not helped or impairment is marked.

• Relaxation also helps alongside other care where physical tension is prominent, as in some headache and chronic pain.

• Relaxation can provoke anxiety: in panic, attending to bodily sensations feeds catastrophic interpretations, and after trauma, dropping vigilance can bring fear, intrusive memories or dissociation.

• Alternatives are grounding, eyes-open practice, shorter exercises or a different technique.

• During exposure, relaxation becomes a safety behaviour if the patient credits it with preventing catastrophe.

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Assertiveness training

Assertiveness means expressing needs, opinions or refusals directly while respecting other people, and accepting that the answer may be no.

Assertiveness is told from aggression by whose rights are respected, not by how firm the person is.

• Technique is modelling, rehearsal, specific feedback and progressively harder real-world tasks.

• Indications include an interpersonal skills deficit, such as avoidance of direct communication in social anxiety, and the interpersonal effectiveness module of dialectical behaviour therapy.

• A patient who lacks the skill is distinguished from one who has it but fears using it.

• In a coercive relationship, assertion can provoke retaliation, so safety planning comes first.

• The communication style is adapted to the patient's culture and goals.

Relapse prevention

Marlatt's relapse prevention model treats a return to addictive behaviour as a process that can be interrupted.

• The person maps their own high-risk situations and early warning signs and rehearses responses: delaying an urge, distraction, contacting support or leaving.

• A lapse is a single episode, which need not become a sustained relapse.

• The abstinence violation effect is when reading a lapse as total personal failure increases continued use.

• A written plan for the first hour after a lapse limits the episode, brings in support and restores coping promptly.

• The model fits substance use and gambling, and in recurrent depression a related approach identifies the relapse signature.

• The model maintains change already achieved, so language is adapted for chronic, fluctuating difficulties with no clear lapse-relapse boundary.

Delivering the work

• Consent covers the anxiety relaxation can cause and the safety assessment before assertiveness work.

• Most learning happens between sessions, so materials are adapted for language, literacy and access, such as audio scripts or group teaching.

• The specific target is tracked alongside symptom measures, and a failing relapse plan prompts asking whether more structured care is needed.