Moving beyond

developments in cognitive and behavioural approaches to theory and practice of therapy

Joseph Curran and Simon Houghton discuss some recent developments in the theoretical and applied areas of cognitive and behavioural therapies, paying particular attention to approaches that form part of a 'third-wave' of behaviour therapies

ognitive behavioural therapy (CBT) is often viewed as a homogenous approach to the understanding and treatment of human distress and has been criticised as a 'mono-therapy' (Hurley and Barratt 2006). It may be more useful to conceptualise the field as consisting of cognitive, cognitive-behavioural and behavioural therapies, as this is a more accurate description of the range of approaches that are used by clinicians in everyday practice and more accurately reflects the philosophical and theoretical origins of the therapies described. The varieties of CBT Far from being a homogenous approach it is possible to identify a range of therapeutic procedures, and some socalled 'brand-name' therapies in the CBT literature (Curran era/2006). These procedures and therapies, at the level of clinical delivery, will each focus on one or more of the areas that are seen to be important in the maintenance of human distress, namely specific behavioural and cognitive processes. Where these approaches differ is in their philosophical assumptions as to the origins of the distress experienced and in the specific techniques used in therapy. For example, cognitive approaches will generally place specific thoughts and thinking process centrally, while behavioural approaches will generally be informed by theories of reinforcement and conditioning. Cognitive approaches and seminal texts on their implementation have been available for several years now (e.g.

Ellis 1962, Beck ef a/1979, 1985). In this article, attention is paid to specific aspects of the contemporary behavioural literature that focuses explicitly on values, spirituality, humanism, narratives, holism, and contextualism. These approaches have their base in the philosophy of science of BF Skinner, which he termed radical behaviourism, but is more currently described as functional contextualism. It is mistaken to report the values of CBT as contrary to those of humanism (e.g. Hurley er al 2005). It is entirely possible, with a correct understanding of behaviourism, to reconcile these views with humanism (Newman 1992). Newman suggests that both humanism and behaviourism share a natural science philosophy of behaviour, but that only behaviourism has developed a scientific perspective to the alleviation of human suffering and the maximising of human potential. Indeed, Albert Ellis, the developer of Rational Emotive Behaviour Therapy was named 'Humanist of the Year' in 1971 by the American Humanist Association, followed by BF Skinner in 1972 who aiso signed the organisation's Humanist Manifesto II. published in 1973. Also in 1972, Skinner and another prominent behaviourist Wiliard Day were engaging in debate about the inherent humanism of (as they were describing) radical behavioural approaches to psychotherapy. The perspective they chose to adopt was to contrast 'humanistic psychology' with 'humanism'. Skinner (1972/1978) wrote: 'I define a humanist as one of those who, because of the environment to which he has been exposed, is concerned

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mechanism:
for the future of mankind' (Skinner 1978). To Skinner, humanistic psychology was concerned with free choice and was basically selfish, leading to excessive aggrandisement of the individual at the expense of attention to the environmental changes that will lead to more effective cultural practices in the fields of education, management and therapy, for example. So, while there may be differences on the varieties of humanism that are being described, it seems unreasonable to deny the behaviourist tradition of working to aid the understanding and improvement of the world of which humans are a part. Indeed, as Grant (2002), in his thorough critique of humanistic and evidence based approaches to mental health nurse education, discusses, the Rogerian view is one based on a perspective of the 'person as omniscient, solipsistic and individualistic, as opposed to a relatively constrained social phenomena'. The central terms to consider bere are contextualism and functionalism, as they are the key pbilosophical differences from the mechanistic and structural approaches that perhaps typify more commonly known or 'traditional' CBT approaches. ContexTuallsm\ In a contextual psychological approach, acts are considered as discrete events embedded in a context that serves to give the act meaning (Pepper 1942). That is, context gives meaning, Bebavioural authors have subsequently described two contextual approaches (Hayes 1993). Descriptive contextualism, where the purpose of an analysis is to identify all the features of context in order that understanding may be reached, and functional contextualism wbere the functions of an act, or behaviour, in its context are analysed not only to aid understanding but also to guide effective action. In clinical behaviour analysis, contextualism is most evident through the explicit attention paid, in varying degrees, to tbe situational, environmental, historical, interpersonal, social, cultural and relationship factors that are, or have been, influential on the person seeking tberapy In addition to these, a contextual approach also explicitly considers tbe therapist, his or her environment and bis or ber sociai, cultural, and personal history as important features that influence the process of therapy, as these are all part of tbe context of the behaviour of humans tbat is called psychotherapy Functlotialism: Functionalism refers to the search for relationships between events, or how one event infiuences another. This approach is derived from Skinner's adoption of Ernst Mach's approach to physics that explicitly rejected Nevirtonian explanations of forces exerted by one body as being the cause of movement in another (Chiesa 1994). Tbe precise identification, descnption and anaiysis of functional relations between events are achieved through the process of functional analysis (see Sturmey 1996). The heart of tbis issue is tbat the function of behaviour is more important than form. That is, the 'purpose' or consequences of an aaion or tbougbt is more important tban what a behaviour looks like, or the content of tbe thought. Clinical behaviour analysts do not suggest tbat the fonn of a behaviour (or group of behaviours) is not important. Rather, structural schemes of symptom classification or diagnosis, while having some utility in research and communication, miss out a crucial feature of behaviour ~ namely its funaion, Tbat is, it might be necessary to identify specific symptoms, but little is revealed about tbe nature and purpose of tbose symptoms for the individual. A padiicular difficulty of attending to form over function is that the same behaviour may have different functions in different settings, and many bebaviours may have the same function (e.g. self-injury, Iwata ef a/1994). For Hayes ef a/(1996), many seemingly unrelated behaviours that take markedly different forms (eg, behavioural avoidance, distraction, substance use, overactivity) function to help people avoid difficult or unpleasant emotion (termed 'experiential avoidance'). A focus on forms of these behaviours would miss out something vitally important in

Symptom elimination
One area in which the field of traditional CBT has been open to criticism has been its emphasis on symptom elimination, or symptom resolution as a primary goal. Alternatives to symptom elimination models based on constructional approaches (after Goldiamond 1974) are well established in parts of the cognitive behavioural field, in which the aims of therapy are to help clients develop more positive, heipfu! behaviours, rather than seeking the elimination of unwanted behaviours or symptoms as a primary goal. This approach necessitates taking a 'whole life' view of and with the client seeking help. Indeed contemporary behavioural approaches (that do not restrict their analysis to overt behaviour, but include thinking as one form of behaviour) have recently begun focusing on principles of acceptance, mindfuiness and def usion that may have parallels with eastern meditative and spiritual traditions, gestalt, humanism, and emotionfocused therapy (Hayes et al ^ 999). Clinical behaviour anaiysis Two behavioural authors and scientists, Dougher and Hayes (2000), use the term clinical behaviour analysis (CBA) to describe the application of behavioural principles to the understanding and treatment of problems seen in adult outpatient settings. They contrast the main features of CBA with those of mainstream psychology, CBA, in their view, is characterised by contextualism, f unctionalism, monism, nonmentalism, non-reductionism and an idiographic approach to people and their problems, that are respectively contrasted with the features of mainstream psychology: mechanism, structuralism, dualism, mentalism, reductionism and a nomothetic approach to human experience. We would argue that criticisms of CBT (e.g. Hurley ef al 2006) might be more realistically applied to some of tbe assumptions and values that underpin some strands of cognitive therapy, but may also be applied to a whole range of approaches to tbe understanding of psychological and emotional problems.

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Acceptance and Comrr}itment Therapy r-4CT'; (Hayes et al 1999), In ACT, the targets for change are the 'second-order processes', such as the context that supports the relationship between thoughts and feelings, rather than the 'first-order processes' of changing thoughts or feelings directly. Central to this approach is the way people develop behaviours or agendas to help them eliminate and controi unwanted aspects of experience (experiential avoidance). Therapy aims to help move people from these essentially unworkable controi agendas by contrasting the consequences of living their life now with the consequences on their wider experience (i.e. one cannot live a full, valued and vital life and avoid anxiety or fluctuations in mood). This is achieved by helping people move from a position of 'not wanting', to one of 'willingness to experience', thereby increasing acceptance, psychological flexibility and moving towards change. It has been suggested (Hayes etal 2006) that ACT shares its philosophical roots with constructivism, narrative psychology, dramaturgy, social constructionism, feminist psychology. Marxist psychology and other contextual approaches, but that the goals of these forms of descriptive contextualism are different, seeking description and understanding rather than prediction and influence.

the experience of that person. 'Functional contextual ism' combines features of these two approaches so that both function and context are explicitly considered. That is, when applied to individuals, questions such as 'What purpose does this behaviour serve for an individual?' and 'What is the context in which it occurs?'. Contrary to the notion that the context of cognition is not considered in CBT (Hurley eta/2006), functional contextual approaches explicitly focus on the context in which thinking occurs, with the main aim being to help alter this context and thereby help change the functions that certain thoughts have, rather than changing their form. Clinical applications We now outline four psychotherapeutic approaches with an emerging evidence base: Acceptance and Commitment Therapy (ACT); Behavioural Activation; Dialectical Behaviour Therapy; and Mindful ness-Based Cognitive Therapy. 22 mental health practice may 2007 vol 10 no 8

Behavioural Activation (Martell ef a/2001) is a therapy approach that is again informed by a philosophy of functional contextualism, in which the functions of the responses commonly seen in depression are more important than the form of those responses. Drawing explicitly from Ferster's (1973) radical behavioural account of depression the important aspects of a person's experience of depression is his or her response to the symptoms rather than, necessarily, the symptoms themselves. These responses, such as withdrawal and avoidance, are seen as part of a person's attempt to manage their own symptoms, but actually serve to further remove them from any positively reinforcing events, thereby maintaining the depressive response though negative reinforcement. From this point of view, the origins or causes of depression may be many and varied - although are often associated with life events. What is important here is that there is usually a change in the contingencies of reinforcement in the person's life so what was positively reinforcing is no longer so (e.g, satiation, 'burnout'), there is a reduced availability of positively reinforcing events, and/or the environment is high in aversive control. With regard to the maintenance of the depressive response, the person's active attempts to deal with his or her symptoms are negatively reinforced, and there may be some positive reinforcement from others. Behavioural activation is a key component of cogniJive therapy for depression (Beck et al 1979), There are, however, some important differences between the approaches. The first is that in cognitive therapy, behavioural activation is seen as way

of collecting thoughts and testing out assumptions. From a behavioural point of view behavioural activation helps people manage their responses to their symptoms differently and increase the positively reinforcing activities in their lives. Second, behavioural aaivation deals with cognition (or thinking) as further symptoms of depression. In dealing with thinking processes commonly seen in depression, behavioural activation looks at the function of thinking rather than the form. So in response to a client expressing what the cognitive therapist might call 'negative automatic thoughts' the therapist involved in behavioural activation would help the client examine the effect of his or her thinking on his or her subsequent responding, rather than help him or her challenge the content (or meaning of the content) of his or her thoughts.

Mindfulness-based cognitive therapy (MBC7). In MBCTthe emphasis is on 'changing awareness of and relationship to thoughts, feelings and bodily sensations' (Segal ef al 2004), rather than changing the content of thoughts. Although the theoretical and philosophical basis of MBCT differs from those discussed above, similarities have emerged. MBCT uses some techniques that have traditionally been part of cognitive therapy approaches, but the use and anticipated effect of these is markedly different. While cognitive therapy broadly aims to help clients change the content of cognition, MBCT uses those techniques that facilitate 'decentreing', that is detaching oneself from the meaning of thoughts and experiencing them as naturally occurring internal events. MBCT was originally developed for use with clients who were at risk of relapse of depression.

Dialectical Behaviour Therapy (DBT): DBT was developed as an applied behaviour therapy for suicidal patients {Linehan Conclusion 1987). This therapeutic approach acknowledges that suicidal CBT is not one homogenous fieid in which all practitioners individuals often feel overwhelmed by change strategies that share a worldview and a very limited set of assumptions. can generate high emotional arousal. Such an emphasis on It is in fact a diverse field in which the relative contribuchange alone often led to disengagement from the therapy tions of thinking, feeling, the environment, and behaviour and so DBT developed a balanced therapeutic stance between to psychological problems are vigorously examined and change and acceptance methods. Change strategies include keenly debated. While it might be possible to identify skills training, problem solving, exposure techniques, and mechanistic, structuralist, and dualistic assumptions in contingency management. These are delivered in a thera- parts of the CBT literature, this is certainly not reprepeutic environment that promotes the acceptance of life's sentative of the field as a whole. We have highlighted inevitable pain resulting from a variety of reasons. What is in this paper how recent developments in cognitive and stressed in the delivery of DBT is that some degree of toler- behavioural therapies are consistent with the alternative ance of unpleasant experience is necessary if the client is to and even contrasting philosophies. While the evidence change a particular problem and that all change strategies base for these approaches is still emerging, they perhaps will inevitably lead to emotional distress. This synthesis of offer additional, and exciting, perspectives on the nature dialectical polarities of change and acceptance is what gives and alleviation of human suffering to those involved in the therapy its name. the delivery of mental health care

Jo5eph Curran RMN, ENB CC650, MSc, and Simon Houghton RMN, ENB CC650, MSc are both Principal Cognitive Behavioural Psychotherapists working at Sheffield NHS Care Trust

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