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Re: Third Wave Behavior Therapies and CT
Jim,
I think that your reply underlines some of the problems that I, as an experienced cognitive therapist, am currently grappling with. I would like to make the following points: 1. Firstly, Cognitive Therapy (CT) is defined as a psychotherapy by its emphasis on changing cognitive content...read all the seminal publications and subsequent ones and prove me wrong on this. The fact that cognitive therapists have , from very early on, routinely integrated techniques from other approaches should not detract from this point. When this type of integration has been applied in a theoretically consistent way it has been used in the service of belief change. However ( and this criticism has been made by John Teasdale and others) very often cognitive therapists have been using interventions that simply do not make sense in terms of the cognitive model...two-chair dialogues, mindfulness meditation, and other mainly experiential interventions. When CT has not used CT techniques to target problems, like simple phobias for example, this seems to me because the theory is simply limited (not, as it appears from your argument, that CT continues to be CT even if it is BT) 2. You say that the targeting of cognitive content continues to be warranted in the treatment of depression "because it works and works well". The best of the research trials show that at least 40 per cent of recipients fail to respond to CT. Thus, our search for better treatments should not stop. To continue to emphasise the targeting of cognitive content in the treatment of depression when we now have 10-15 years of research findings suggesting that it is the cognitive process of rumination that is the main feature of depressive cognition seems to me to be irresponsible. Furthermore it raises the question as to why a therapy that seems to have been so clinically liberal in the past (even if this was theoretically incoherent in many ways) seems now to have have lost clinical flexibility when it comes to an apparently indisputable empirical finding. Can Cognitive Therapy become a dinosaur? Last edited by Sharkey; September 25th, 2004 at 03:02 AM.. |
#12
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Is CT defined by interventions designed to change cognitions? (Part 1)
Your idea of looking back to seminal works and also at subsequent ones is a good one (though my point isn't to prove you wrong). Certainly, trying to change the content of cognitions is a very important part of CT and one can build a good argument that it is a defining characteristic of CT. However, even in early publications, the emphasis was not solely on changing cognitions. In Cognitive Therapy and the Emotional Disorders, Beck (1976, pp. 214-215) wrote:
“In the broadest sense, cognitive therapy consists of all the approaches that alleviate psychological distress through the medium of correcting faulty conceptions and self-signals. The emphasis on thinking, however, should not obscure the importance of the emotional reactions which are generally the immediate source of distress. It simply means that we get to the person’s emotions through his cognitions. By correcting erroneous beliefs, we can damp down or alter excessive, inappropriate emotional reactions.In Cognitive Therapy of Depression (Beck, Rush, Shaw & Emery, 1979, p. 117) the chapter on behavioral techniques preceeds the one on cognitive techniques and it clearly asserted that CT includes much more than the application of cognitive techniques: “The cognitive therapy of depression is based on the cognitive theory of depression. By working within the framework of the cognitive model, the therapist formulates his therapeutic approach according to the specific needs of a given patient at a particular time. Thus the therapist may be conducting cognitive therapy even though he is utilizing predominantly behavioral or abreactive (emotion releasing) techniques.â€This also makes it clear that if the therapist is using interventions that don't make sense in terms of the cognitive model, they aren't doing good CT. This applies if one is using a "non-cognitive" technique in a way that doesn't make sense conceptually or if one is using a cognitive technique in a way that doesn't make sense conceptually. Using thought sheets inappropriately isn't good CT. Using mindfulness training or gestalt "empty chair" techniques can be good CT if it is done in a way that makes sense conceptually. It is important to remember that the “seminal works†were written 25 or 30 years ago and that CT has evolved a bit since then. For a contemporary statement of CT’s view, consider the following excerpts from the chapter that Dr. Beck and I wrote of the second edition of Major Theories of Personality Disorder (Clarkin & Lenzenweger, 2004): “Cognitive Therapy is based on the proposition that much psychopathology is the result of systematic errors, biases, and distortions in perceiving and interpreting events. These cognitive factors are seen as resulting in dysfunctional responses to events which, in turn, may have consequences which serve to perpetuate the dysfunctional cognitions. Theoretically, the focus is strongly on the interaction between the individual and his or her environment rather than emphasizing either individual or situational factors in isolation (for a detailed example see Pretzer, Beck, & Newman, 1990). Individuals' interpretations of events are seen as playing a central role in many forms of psychopathology, and these interpretations are seen as being the product of the interaction between the characteristics of the individual and the nature of the events the individual encounters. However, in discussing treatment, much more emphasis is placed on individual factors (such as dysfunctional beliefs) than on situational factors (such as negative life events) because therapist and client are more able to modify individual factors than situational ones. |
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Is CT defined by interventions designed to change cognitions? (Part 2)
Yes, I said that the targeting of cognitive content is warranted in the treatment of depression "because it works and works well" and I think that's a pretty good arguement. However, I don't mean to suggest that we should not continue to try to increase the effectiveness and try to find more effective approaches. A significant number of people do not benefit from CT. Some of these don't get an adequate trial of CT (i.e. they discontinue treatment prematurely) and others show little or no improvement despite an adequate trial of CT. You are completely right that our search for better treatments should not stop. If any of the "Third Wave" approaches turn out to be more effective than "standard" CT, I'll be arguing that we should either switch to those approaches or integrate them into CT.
In addition, we should do some research into the characteristics of individuals who terminate treatment prematurely or show a poor response to CT. I can remember a study or two that suggest that co-occurring Axis-II disorders may account for a substantial portion of these cases. Perhaps we're discovering that when there are co-occurring disorders (Axis-II, substance abuse, marital problems, etc.) we need to treat those problems as well rather than trying to treat the depression in isolation. (Remember that in those well-controlled outcome studies the treatment protocols focus on depression without much attention to co-morbid disorders.) So why do I continue to emphasise the targeting of cognitive content in the treatment of depression when we have research suggesting that rumination that an important feature of depressive cognition? Because I've seen good evidence that CT based on targeting cognitive content is effective much of the time and I haven't seen good evidence that other treatment approaches are more effective. I've been keeping an eye on the "third wave approaches and will adopt them if they turn out to work better. If any studies showing that they work better have been published, I haven't seen them yet. You suggest that my stance "raises the question as to why a therapy that seems to have been so clinically liberal in the past (even if this was theoretically incoherent in many ways) seems now to have have lost clinical flexibility when it comes to an apparently indisputable empirical finding". It sounds as though you may have misunderstood my position. I am not suggesting that CT should be inflexible or that we should only focus on changing cognitive content. I'm very much in favor of clinical flexibility and of adding new intervention techniques to CT (while remaining theoretically coherent). Personally, in addition to working to modify dysfunctional thoughts and beliefs, I also target depressive rumination, use a number of DBT techniques, use acceptance-based interventions, and am starting to use mindfulness more frequently. However, I don't buy the idea that we should abandon interventions that focus on cognitive content for some reason since those interventions are effective with many clients. |
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Can CT become a dinosaur?
CT certainly can become a dinosaur if we cease to learn and evolve. If new data, theoretical advances, and clinical innovation are ignored, CT will gradually become outmoded.
However, why should we cease to learn and evolve? There have been many advances since the seminal works were written nearly 30 years ago and fortunately we do not have to remain in the 1970s. All we need to do is to be open to new ideas, test them, and take the data seriously. If we do this, CT will evolve over time, retaining the features that prove effective and adopting new concepts, strategies, and techniques when they benefit our clients. |
#15
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Empirical Support for "Third Wave" behavior therapy
Those who have been wondering about the empirical status of "third wave" approaches will find a recent review by Steve Hayes et al (2004) useful. Hayes and his colleagues review the empirical support for Dialectical Behavior Therapy(DBT), Acceptance and Committment Therapy (ACT), and Functional Analytic Psychotherapy (FAP) and conclude that DBT and ACT each "have a small but growing body of outcome research supporting these procedures and the theoretical mechanisms though responsible for them" while FAP "has a limited research base, but its central claim is well substantiated." The authors don't explain why they chose just these three approaches to review. A number of other "third wave" approaches have decent empirical support as well. However, it looks as though this article gives a good overview of the available evidence.
Note: My only complaint about proponents of "third wave" approaches (not Hayes et al, 2004) it that they often talk as though empirical support for "third wave" approaches somehow invalidates more established CBT & BT approaches. Obviously, the finding that these approaches work does not invalidate all the evidence that established CBT and BT approaches work well with a broad range of problems. If proponents of these approaches stuck to saying that they've come up with interesting new approaches which we all may be able to learn from, I'd have no quarrel at all. For some reason, they often seem compelled to argue that evidence of the effectiveness of their approaches somehow proves that all other approaches are wrong, or at least hopelessly outmoded. Hayes, S. C., Masuda, A, Bissett, R., Luoma, J. & Guerro, L. F. (2004). DBT, FAP, and ACT: How empirically oriented are the new behavior therapy technologies? Behavior Therapy, 35, 35-54. |
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