Contextual Cognitive-Behavioural Therapies

I have a terrible confession to make about my background as a clinical psychologist: I trained as a behaviourist.

Why is this “terrible”? Well, because I now work in the UK, where it seems that behaviourally-oriented clinical psychologists are scarce (at least in my field), and I am a member of the British Association for Behavioural and Cognitive Psychotherapies, where the dominant paradigm is cognitive.

The dominance of the cognitive paradigm to CBT is so complete in the UK that it appears trainee clinical psychologists and CBT therapists are taught very little about basic behavioural principles, functional analysis, or therapeutic approaches that have developed from the behavioural wing of CBT. Behavioural criticisms of a cognitive approach are seen as out-dated, equated with stimulus-response psychology, or just plain weird. BF Skinner is treated with as much disdain as Freud. Behavioural methods are regarded as part of a CBT package, but it is widely believed that the “really effective” components are cognitive (thought challenging etc.). Proponents of modern behavioural approaches presenting their work in the UK are liable to experience harsh (and most times, ill-informed) criticism from the custodians of the CBT approach.

Professor David Richards writes in the March 2007 BABCP magazine about the apparent arrogant and inflexible attitude displayed by CBT therapists toward other therapies (in response to Henck Van Bilsen’s article in the previous edition encouraging CBT therapists to celebrate the field’s successes, particularly the evidence base). This attitude unfortunately also extends to the behavioural approach:

“Nor is this attitude confined to an arrogant dismissal of other supposedly ‘non evidence-based psychotherapies’. Despite Henck claiming that CBT is a ‘large house with many rooms’ the voice of the cognitive lobby within CBT has drowned out most other approaches. At a meeting recently [of the BABCP] I was astonished to hear a very senior person in our fraternity unable to comprehend that a member of the CBT family of treatments could be conceptualised outside of a cognitive paradigm, could even regard cognitions as inconsequential private events. All this despite the treatment in question – a contextual, socialbehavioural one – being the subject of nearly 20 randomised controlled trials demonstrating at least equivalent effectiveness to cognitive therapy. Henck makes the same mistake by asserting that ‘A core element of all cognitive behavioural interventions is that they work towards change by influencing thinking.’ Not so Henck.”

Well, for the sake of balance my little blog is going to list some of the modern behavioural approaches to CBT, in the vain hope that UK CBT therapists will chance upon it and follow some of the links. It seems a shame to me that UK CBT therapists are not at least made aware of the work that is being done by behaviour analysts that speaks directly to the reasonable theorectical and technique-based concerns about cognitive therapy (see here for a blog discussion of a recent meta-analysis regarding the empirical status of thought challenging; Longmore & Worrell, 2007).

The modern behavioural approach to CBT is contextual, and this philosophical stance informs how cognitions (private events) are viewed. Cognition is not assumed to be causal for overt behaviour, instead cognition is regarded as a form of behaviour itself, and the interest for contextualists is in the historical and current environmental variables that may influence the occurrence, incidence, prevalence, or probability of behaviour, both overt and private. Contextualists take a pragmatic approach, being interested in what predicts and influences behaviour. Models of psychological problems that have predictive power but do not identify how to influence or change problems are of limited use pragmatically. A contextualist will focus on identifying potentially manipulable environmental variables in the functional analysis of a client’s problems; the behaviour of the therapist is considered a “manipulable environmental variable” and the social context of therapy as an influential environment to produce change, hence the focus in these therapies on creating powerful therapeutic relationships.

Enough philosophy and theory. Below is a list of these contextual CBT approaches, with links to discover more about them:

Acceptance and Commitment Therapy – incorporating mindfulness, acceptance and behaviour change methods to enable clients to live valued lives, ACT is based upon a behavioural account of cognition (Relational Frame Theory) and has a developing evidence base of both randomised controlled trials, mediational studies, that links to basic science about language. (check out the link here)

Dialectical Behavior Therapy– originally developed for the treatment of women with emotional vulnerability who coped with self-injury or suicidal behaviour, DBT incorporates acceptance and change methods, including mindfulness and CBT emotional regulation skills. DBT also involves an explicit program for the psychological care of therapists who work with challenging clients. (check out the link here)

Functional Analytic Psychotherapy – based upon a behaviour analytic approach to the therapeutic relationship, FAP focuses on how therapists can create powerful, influential therapeutic contexts through functional analysis of in-session behaviour. (link here)

Behavioral Activation Therapy– demonstrating equal or superior effectiveness to cognitive therapy in the treatment of depression, the contextual approach of BA does call into question the assumption that cognitive methods are the essential component in CBT for depression. (see a description here)

Happy Reading!

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  1. Pingback: Is the functional analysis of behaviour important? – Eric Morris, PhD

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