Cognitive Behavior Therapy, 2023, Chand et al

[Andy]

Continuing Education Activity
In the 1960s, Aaron Beck developed cognitive behavior therapy (CBT) or cognitive therapy. Since then, it has been extensively researched and found to be effective in a large number of outcome studies for psychiatric disorders including depression, anxiety disorders, eating disorders, substance abuse, and personality disorders. It also has been demonstrated to be effective as an adjunctive treatment to medication for serious mental disorders such as bipolar disorder and schizophrenia. CBT has been adapted and studied for children, adolescents, adults, couples, and families. This activity reviews the efficacy of CBT in both psychiatric and non-psychiatric disorders and the role of the interprofessional team in using it to improve patient outcomes.

Objectives:

• Identify the key concepts of cognitive-behavioral therapy.
• Describe the indications for cognitive behavioral therapy.
• Outline the structure of cognitive behavioral therapy sessions.
• Review the clinical significance of cognitive-behavioral therapy and its efficacy in treating common psychiatric illnesses.

https://www.ncbi.nlm.nih.gov/books/NBK470241/

 

[Andy]

"Introduction

In the 1960s, Aaron Beck developed cognitive behavior therapy (CBT) or cognitive therapy. Since then, it has been extensively researched and found to be effective in a large number of outcome studies for some psychiatric disorders, including depression, anxiety disorders, eating disorders, substance abuse, and personality disorders. It also has been demonstrated to be effective as an adjunctive treatment to medication for serious mental disorders such as bipolar disorder and schizophrenia. CBT has been adapted and studied for children, adolescents, adults, couples, and families. Its efficacy also has been established in the treatment of non-psychiatric disorders such as irritable bowel syndrome, chronic fatigue syndrome, fibromyalgia, insomnia, migraines, and other chronic pain conditions."

References given for this section do not support the claim here for CFS. However, in another section

"CBT is based on a straightforward, common-sense model of the relationships among cognition, emotion, and behavior.[4][5][6][7]"

Reference 7 is Prediction of long-term outcome after cognitive behavioral therapy for chronic fatigue syndrome, 2019, Knoop et al

 

[Hoopoe]

The ideology of CBT seems to be partially responsible for the testimonial injustice suffered by people with ME. The descriptions of our illness are interpreted as cognitive distortions and exaggeratedly negative, even self-destructive and the main cause of disability (which implies the degree of distortion in our cognitions must be extreme).

I say partially because this injustice happens even in situations where CBT has probably no influence on how patient words are interpreted. But CBT will make these existing tendencies to injustice worse, and it's clear that it has had a lot of influence in healthcare settings where ME patients are not taken seriously.

Patients with chronic pain might be told that they are catastrophizing (a type of cognitive distortion). I think that those who haven't experienced severe chronic pain apply the catastrophizing label because of their own inability to understand how bad it is. It seems to be that with CBT there is a risk that any subjective experience or personal situation that is hard to understand for those who haven't experienced anything like it before, be labelled as a cognitive distortion. Which would probably make the suffering worse or even hinder the patient in finding solutions.

 

[Hoopoe]

I also wonder how brain fog affects the impression that others have of us. If you have not enough energy to think and communicate properly, you're probably likely to appear to suffer from cognitive distortions. But these are not so much an ingrained false view of the world as a way to communicate the essential points while not having enough energy to elaborate on all the details.

If I said "activity makes me worse" this is probably a lot more likely to be interpreted as distorted cognition than a long a detailed description of all the details and experiences this is based on. And patients can easily be forced by circumstances and lack of energy to omit many details. Visits at the doctor or therapist are the kind of circumstance where patients can become mentally exhausted.

 

[JemPD]

@strategist you are so, so right!

 

[Dolphin]

I also wonder how brain fog affects the impression that others have of us. If you have not enough energy to think and communicate properly, you're probably likely to appear to suffer from cognitive distortions. But these are not so much an ingrained false view of the world as a way to communicate the essential points while not having enough energy to elaborate on all the details.

If I said "activity makes me worse" this is probably a lot more likely to be interpreted as distorted cognition than a long a detailed description of all the details and experiences this is based on. And patients can easily be forced by circumstances and lack of energy to omit many details. Visits at the doctor or therapist are the kind of circumstance where patients can become mentally exhausted.

 

[Sean]

CBT, and more broadly any directive psychotherapy, necessarily assumes the therapist knows both general reality and the reality of patient's life better than the patient.

Which is one hell of an assumption, for which I have never seen a shred of evidence.

If anything, for ME at least, the evidence clearly points the other way.

 

[Peter T]

CBT, and more broadly any directive psychotherapy, necessarily assumes the therapist knows both general reality and the reality of patient's life better than the patient.

My unreliable memory of how CBT was described when I was a psychology undergraduate some forty five years ago was that it was not based on any models of causation rather that it sought to change present behaviour without any assumptions about psychological aetiology. It was presented as an antidote to such as psychoanalysis which delves endlessly into the history of an individual’s psyche. Obviously there is an implicit assumption that it will only work for behaviours circumscribed by preconceptions and habits so are changeable, so it would help someone who wants to exercise more but feels too self conscious to go to the gym, but would not help someone who is too ill to undertake any physical exertion.

Similarly my memory is that it required agreement between the practitioner and the patient, a setting of common goals. So there should be explicit agreement about what the intervention is aiming to achieve, but also implicitly that both clinician and the patient believe changing the relevant cognitions can achieve the desired behavioural changes. However I don’t remember it being explicitly explained how to establish what change is possible in reality. For example CBT can never help anyone achieve unaided flight no matter how much they and their clinician feel it would be a desirable outcome. Alternatively it might be rational to have CBT aimed at reducing a gambling addiction, but not CBT aimed at winning the lottery.

Any theory about any specific condition or set of symptoms is not an inherent component of the CBT itself, so the patient and the practitioner must either agree the target behaviour is changeable or the patient must agree to accept the practitioner’s understanding is superior to theirs.

It is not inherent in CBT as originally formulated (at least in my understanding) that with ME/CFS the goal of intervention must be to increase activity, it is equally rational to formulate CBT for people with ME/CFS aimed at decreasing levels of activity. If you believe that ME/CFS is purely behavioural related to false cognitions then it is rational to use CBT to seek to increase activity levels, but if you understand ME/CFS involves bio medically imposed activity ceilings exceeding which will worsen the condition, then, for those for who find it difficult to avoided worsening their condition, CBT aimed at maintaining lower levels of activity is a rational option.

So PACE type CBT is not a necessary consequence of CBT, rather a reflection of the understanding or beliefs about ME/CFS of those that provide it. What is of interest is how the practitioners convince their patients that changing cognitions will allow significant increases in activity, especially when there is no evidence that for this patient group it achieves anything beyond short term change questionnaire filling behaviour, and what little evidence we do have implies that contact with the specialist services that provided this resulted in reduced activity overall?

 

[JemPD]

My main issue with CBT is the premise that creates a hierarchy between thoughts, emotions & behaviour
ie that cognitions are the top, the most important, because they are the root of feelings > which lead to behaviours > which leads to results... and around we go.

But from my own experience i dispute that.... thoughts are often well downstream of the emotion, such that it takes me ages to figure out a thought to explain the way i'm feeling. The emotion's been generated by my brain/nervous system as a result of having seen/heard experienced something that was similar to something my brain has learned is dangerous (for example). They dont stem from a thought.

And this

CBT, and more broadly any directive psychotherapy, necessarily assumes the therapist knows both general reality and the reality of patient's life better than the patient.

This is why i object to all types of therapy being labelled 'psychotherapy' and considered to be roughly the same, whereas the theoretical/philosophical underpinnings between say CBT & non directive humanistic therapy are just so far apart as to be chalk & cheese.

I'm not suggesting there is evidence for any of them, or that we know that one 'works' better than another, but Psychoanylitic, Cognitve, Cognitive Behavioural, & Psychodynamic, all largely have as a starting point that the therapist understands the world better than the patient, they are the experts and are going to apply a treatment. It may be 'collaborative', but at its heart its still a Dr-Patient dynamic.

As opposed to an egalitarian 'you're the expert on you' with the therapist seeing themselves as a supportive non judgemental sounding board rather than teacher/guide. Which you tend to find more in Humanistically oriented therapies.

Of course psychoanalysts & CBT practitioners would argue with that but in my (considerable) experience of counselling/therapy for trauma related stuff, this is what has been borne out.

@Brian Hughes discusses the different types of therapy in his book Crisis in Psychology.

 

[Hubris]

My unreliable memory of how CBT was described when I was a psychology undergraduate some forty five years ago was that it was not based on any models of causation rather that it sought to change present behaviour without any assumptions about psychological aetiology. It was presented as an antidote to such as psychoanalysis which delves endlessly into the history of an individual’s psyche.

This is purely a marketing move. The psych lobby knew that therapy had to be changed to go mainstream. Psychoanalysis didn't truly fit their needs because claiming that everyone has some hidden childhood trauma wouldn't sit well with many. Most people do not actually have any so you would risk getting stuck with your "analysis" and blowing your cover.

CBT is the magic bullet, it just works, no matter what your problem is!

You can't cure someone by talking to them, so this is just the same BS packaged differently. I've done both CBT and more classic psychoanalysis, i can't tell any real difference. Every time it's just a gross showcase of incompetence by someone who has absolutely no clue what they're talking about. It's like listening to an astrology lecture.

 

[Hoopoe]

My main issue with CBT is the premise that creates a hierarchy between thoughts, emotions & behaviour
ie that cognitions are the top, the most important, because they are the root of feelings > which lead to behaviours > which leads to results... and around we go.

I also do not experience my own cognition like that at all.

I think there are indistinct cognitive processes that have little to not verbal or emotional component. These go on and when they reach a conclusion they can be expressed into well defined thoughts and emotions, like "it would be nice to do this today" or the feeling of satisfaction.

This is another reason to think CBT is wrong. I just need to observe my own cognitive processes to see that verbally expressed thoughts are not in command. Verbal thoughts are just small cog in a machine. The heavy work is done on the non-verbal side. I'm skeptical of the idea that changing my verbally expressed thoughts is truly changin my thinking. If I do that, I think I'm just imitating a change in thinking rather than making it real. To change thinking requires something that we might call a learning process.

I've wondered before if maybe the way I think is very intuitive compared to other people. A lot of thinking goes on, and I can express that in verbal form if I make the effort to do so, but it's just more convenient to let it go on for a few moments or a while and let it reach a conclusion.

 

[JemPD]

I also do not experience my own cognition like that at all.

I think there are indistinct cognitive processes that have little to not verbal or emotional component. These go on and when they reach a conclusion they can be expressed into well defined thoughts and emotions, like "it would be nice to do this today" or the feeling of satisfaction.

This is another reason to think CBT is wrong. I just need to observe my own cognitive processes to see that verbally expressed thoughts are not in command, but more like an output with some freedom of expression, that can also feed into more cognitive processes. Verbal thoughts are just small cog in a machine. The heavy work is done on the non-verbal side. I'm skeptical of the idea that changing my verbally expressed thoughts is truly changin my thinking. If I do that, I think I'm just imitating a change in thinking rather than making it real. To change thinking requires something that we might call a learning process.

I've wondered before if maybe the way I think is very intuitive compared to other people. A lot of thinking goes on, and I can express that in verbal form if I make the effort to do so, but it's just more convenient to let it go on for a few moments or a while and let it reach a conclusion.

Just to clarify... I wasnt talking about verbally expressed thoughts. I was meaning thoughts, full stop.

ie i get emotions with absolutely no thought that goes with them, none.

Its internal thoughts (ie non verbalised), that is part of what CBT is supposed to address.... because the idea goes, that they are what lead to feelings and then feelings to behaviour. What i am saying is that it is very possible to have emotions first, and then have to search around for a long while to work out a thought that might go with them. So the idea that everything stems first from distorted cognitions is, IMO false.

When i say 'thought' i dont mean something verbalised, that would be a verbalised thought, which may or may not occur.

 

[Hoopoe]

ie i get emotions with absolutely no thought that goes with them, none.

Me too. Aren't these often the best and most authentic?

It's tricky to talk about these things because there no clear definitions for the various concepts like thoughts.

 

[shak8]

My take on CBT is that the list of cognitive distortions might be useful to know. But they are not infallible.

The concept of pain catastrophization is bizarre. Two days ago I had a new source of pain that was indeed a catastrophy (to me). I knew that it would subside in a couple of days. But that didn't stop the flood of pain signals, the pain amplification that happens in FM.

CBT was originally used for treating depression and I can see the catastrophizing tendency of depressed thinking. But that doesn't mean one can simply adapt these concepts to other conditions, willy-nilly.

My friend's anxiety didn't get better with CBT, so she graduated to ACT, an off-shoot of CBT. There she set "goals" which were behaviors that were to reflect her "values." What this meant is she does no introspection and frequently exceeds what her body can tolerate.

I am not a fan of any tract of psychotherapy.

.

 

[rvallee]

CBT was originally used for treating depression and I can see the catastrophizing tendency of depressed thinking. But that doesn't mean one can simply adapt these concepts to other conditions, willy-nilly.

I read a few times descriptions of depression that seem to be, IMO, what should legitimately be called depression. I cannot relate to this description at all, has nothing whatsoever to do with what I experience with chronic illness.

It is based around negative self-thoughts, kind of an inner voice that is bullying the person from the inside, calling them worthless, how everyone hates them, how they would be better off dead. They are very intrusive thoughts that are excessive and non-stop. It's relentless self-bullying with a clear start, has nothing to do with prior mood or personality.

And that seems to be the version of depression that makes sense as described and should be amenable to something like CBT, although I suspect that any generic attempt to reframe the thoughts would work just as well. Not that it makes it easy, but it makes some minimal sense, unlike almost everything around the nexus of MUS as basically mood disorders, or whatever.

That version of depression has nothing to do with symptoms, or illness, or fatigue, even little to do with motivation. I don't know how common this is, if it's closer to what most people would self-describe as depression. But it makes sense to apply that solution to that problem.

However depression is usually defined by symptoms, mostly involving the most common symptoms of illness. So that's a very different thing. But clearly no one is able to tell the difference anyway. I really doubt that much of what is the current models will survive beyond a few years, it's just archaic legacy stuff, placeholder ideas that haven't been cleaned up in decades and accumulated a technical debt so big that no one dares call it out.