Centre of Excellence Online – Cognitive Behavioural Therapy (CBT)

1. What is Cognitive Behavioural Therapy?

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 Centre of Excellence Online – Cognitive Behavioural Therapy (CBT)

1.1 Introduction
Cognitive Behavioural Therapy (CBT) is a popular form of psychotherapy that is now widely
used by psychologists, counsellors and mental health clinicians.

CBT has become the treatment of choice for many disorders, such as depression, anxiety and
problems with anger, due to the sound empirical basis for its effectiveness.

It emerged in the 1960s, when two influential schools of thought in the history of psychology,
cognitive theory and behavioural theory, united to form a powerful intervention applicable
to a range of disorders. The pioneer of CBT was Aaron Beck, a psychiatrist at the University of
Pennsylvania. He studied and practised psychoanalysis, and carried out many experiments
relating to depression. He was surprised to find that patients often had what he termed
"automatic thoughts", which fell into three categories: negative thoughts about themselves,
the world and/or the future.

Beck began helping patients to work through these automatic thoughts, so that they would
think in a more realistic manner. As a result, these patients began to feel better emotionally
and it resulted in long-standing change. He initially termed this approach "cognitive therapy”,
but it has since become known as "cognitive behavioural therapy”.

Since its introduction, CBT has been widely studied and, through an empirical framework,
proven to be very effective in treating a range of disorders, such as psychiatric problems,
psychological problems and medical problems. Today, it is most commonly used to treat a
range of mental health problems, chronic pain and suicide prevention.

CBT is focused on the present: it's time limited and is problem-solving focused. Within this
therapeutic framework, patients learn specific skills they can use throughout their lives. This
involves identifying and altering negative thought patterns, belief systems and relating to
others in more positive ways. By altering thinking patterns, behaviour change is activated.

It's based on the notion that the way we perceive the world influences how we feel
emotionally. It is people's thoughts about a situation that affect how they feel, not the actual
situation. The emphasis is on problem-solving and behavioural change. This is how it succeeds
in being a time-limited and structured intervention that helps patients deal with their
problems quickly and efficiently.

To understand fully the amalgamation of CBT, you must first understand the history of
cognitive psychology and behaviour psychology.

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 Centre of Excellence Online – Cognitive Behavioural Therapy (CBT)

1.2 History of Cognitive Psychology

Cognition is a broad term that encompasses thought processes and mental behaviour.
Cognitive psychology is a general approach to psychology that focuses on the internal
mental processes. Cognitive psychologists are interested in thoughts, attention, memory,
comprehension, consciousness, perception, language, reasoning and problem solving
abilities.

This area of psychology examines the "higher" cognitive processes, like memory, reasoning,
information processing, problem-solving, decision-making and creativity.

Cognitive psychology is the scientific study of the thinking mind and is concerned with:

 How we attend to and gain information about the world

 How that information is stored and processed by the brain
 How we solve problems, think and formulate language

It's a broad area of psychology and so the range of topics explored by psychologists working
from this perspective is diverse.

Ancient philosophers and early psychologists have been fascinated with knowledge and the
human mind. Wilhelm Wundt and William James really pushed forward the movement of
cognitive psychology beyond philosophical speculation and into the scientific realm. Their
contributions to the field have influenced the techniques, subject matter, procedures and
even the interpretation of results used by contemporary psychologists.

Three widely known models developed in cognitive psychology include:

1. Schema theory: a schema is a cognitive framework of meaningfully organised

concepts. Schema theory plays a major role in modern theories of memory. This is an
area we will explore in more detail in this module.

2. Information-processing model: rescheduled to a time-ordered sequence of events.

Cognition can be understood by analysing it into a series of sequential stages. At
each stage, unique processes take place on incoming information and receive
information from preceding stages.

3. Neuroscience model: Focuses on the underlying brain function that produces

cognitive experience.

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Cognitive schemas

Social cognition involves thought processes and structures that are influenced by and that
influence social behaviour. A cognitive schema is a structure that signifies knowledge about
a person or stimulus, and it includes thoughts, beliefs and attitudes.

Social schemas are ideas that are organised into categories of social events and people.
They help people process and store the plethora of information they absorb about social
interactions. There are many types of schemas, which all influence the way information is
encoded; and when a schema is activated, it is likely to influence perceptions of a person.

Some of the schemas that individuals apply to people are unique products of their personal
experiences, while other schemas may be part of their shared cultural background.
Stereotypes are special types of schemas that fall into the latter category.

All schemas influence the way in which we store information in our memories and how we
perceive future situations.

Type of schema Description Example

Person schemas These are exclusive information You may consider your
structures about specific people. It colleague to be friendly and
may be about your best friend, a intelligent, but she has
neighbour or a politician. difficulties speaking in public.

Role schemas These are information structures A doctor is usually viewed as a

about the function or behaviour of near stranger and yet you
a role in particular situations or discuss personal information
social groups. with them and often have
medical check-ups that
require you to undress.

Scripts These are schemas about events When you eat out at a
that help us make sense of a restaurant, it may invoke a
situation and guide our behaviour. 'restaurant schema' about
what might occur at a
restaurant. For instance,
someone seats you at a table,
they give you a menu, you
make your order, you eat and
talk, and then you pay the bill
and leave.

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Content-free These are schemas that do not If you are friends with Peter
schemas contain detailed information about and Peter is friends with
a particular category. James, then you may assume
that you will like James as
well.

Self-schemas These are the schemas that we You might think of yourself as
have about ourselves. It is how we a strong, open-minded person
represent and store information who loves ice-cream.
about how we see ourselves and
forms one’s self-concept.

Once a schema is activated, we tend to fill in the gaps with the prior knowledge and
presumptions we have stored in our memory, rather than gather direct information from
the setting in which we are.

Influences on schemas

There are many factors that influence what schemas we use and the costs involved when
we do so. Some of the individual differences include:

o Self-schemas
o The desire to think deeply
o Desire to remain informed
o Cognition complexity
o Goals of communication

One of the goals of evoking a schema is to help orientate and make us feel that we have
some knowledge about the situation in which we find ourselves. When we are indecisive
and unable to evoke a schema, we may experience the following:

o Stress and anxiety

o Pressure to perform
o Communication difficulties

However, sometimes when we evoke a schema based on our prior experiences and
presumptions, we may also have to be privy to the repercussions. For example, if you have
only ever worked with women whom you believe are passive, then you may behave toward
your new female colleague in a way that makes her feel dismissed or ignored.

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 Centre of Excellence Online – Cognitive Behavioural Therapy (CBT)

1.3 History of Behavioural Psychology

In the early 1900s, John B. Watson made his mark on psychology when he founded
behaviourism. It is an approach to psychology based on the premise that only observable
behaviour should be scientifically investigated. He claimed that the importance placed on
introspection by competing schools of thought was too subjective. A proper scientific
approach entails the study of only observable and measurable behaviour. For Watson, mental
processes were not a subject that could be studied properly, because they rely on personal
experiences.

His ideas were termed radical behaviourism, as he proposed that psychologists discard the
study of consciousness and focus solely on behaviours that could be directly observed. The
implications of Watson’s theory on how psychology was viewed at the time were colossal. He
attempted to redefine the essence of psychology as a science. He insisted that psychology be
the study of behaviour, rather than the study of the mind.

In the 1950s, B.F Skinner supported the earlier beliefs of Watson's focus on observable
behaviour. Though he didn't deny the existence of internal mental events, he insisted that
they could not be studied scientifically. For Skinner, the environment controls behaviour, not
the person. The link of mental processes does not account for behaviour and, in fact,
complicates things.

Skinner's analysis of behaviour was reflective of Darwinian evolutionary theory. Charles

Darwin proposed that a human is constantly generating forms of behaviour. Some of this
behaviour leads to favourable consequences, which are reinforced. Those behaviours are
strengthened as they contribute to the person's survival. The acts that are not reinforced are
not learned and disappear from the human's repertoire. This was a similar view to that of how
weak species become extinct, as theorised by Darwin.

Skinner initiated a systematic research programme to focus on a new kind of behaviour, the
operant. According to Skinner, people's personality characteristics are shaped by reinforcers
that follow behaviour. For example, if you tell a joke at a party and people laugh and give you
attention, then your tendency to be humorous will be strengthened.

How behaviour is learnt

Skinner identified a form of learning in the 1930s which became known as operant
conditioning. The association is between the response and reinforcement, rather than the
stimulus and response. Operant conditioning is the process in which behaviour is
strengthened through reinforcement. When a response is produced, it is more likely to be
repeated if it is reinforced. It works on the notion that behaviour can be shaped through
reinforcement.

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Before operant conditioning, there was a term introduced earlier by Edward L. Thorndike,
known as instrumental learning. He set out to find out whether animals could think and
conducted some memorable studies of problem-solving behaviour in cats.

In the study, food was placed just outside a cage, known as a puzzle box, while a hungry cat
was placed inside. By performing a specific response, such as pressing a lever or pulling a
wire, the cat could escape and get the food. When the cat escaped, it was rewarded with
food and then returned to the cage for further trials. Thorndike hypothesised that if cats
could think, then there would be a sudden fall in the response time required to escape
when they recognised the problem's solution. Instead, Thorndike discovered a gradual
decline in the response time for escape, which he believed was as a result of learning. This
learning was not attributed to thinking but to what he termed the law of effect. In the
presence of a stimulus, if a response leads to a rewarding outcome, the link between the
stimulus and the response is reinforced.

His work provided the foundation for the ideas proposed later by Skinner.

Skinner's famous experiment

Skinner’s renowned experiment was based on studies of rats. He placed them in what is
now known as the Skinner box, where specific responses were recorded while the
consequences were controlled. When the rats voluntarily pressed a small lever on the side
of the box, their hunger was reinforced by food pellets. Thus, the food or reinforcement
increases the rat’s drive to touch the lever.

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Terminology

Stimulus (S)  Response (R)  Reinforcement (R)

There are two types of reinforcement:

Positive reinforcement is when a response is strengthened by adding a stimulus, e.g. when a

child gets pocket money for cleaning their room.

Negative reinforcement is when a response is strengthened by removing a stimulus, e.g.

when a child’s pocket money is removed for not cleaning their room (therefore, they’re
more likely to clean their room in the future).

Other processes are also at play in operant conditioning:

Acquisition refers to the first stage of learning a new pattern of responses. Responses in
operant conditioning are generally established through the process of shaping. This shaping
involves the reinforcement of smaller and smaller estimates of a preferred response.

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The weakening of a response over time when it is no longer reinforced is known as

extinction, e.g. if the child who cleans their room eventually stops getting pocket money,
they may stop cleaning their room as the reinforcer has been removed.

Punishment is an event that decreases the likelihood that behaviour will continue, e.g. a
child that has a tantrum in the confectionary aisle of a supermarket is not given the much-
wanted lollipop (so is less likely to have another tantrum when next in the shopping aisle).

While punishment can act as a way to deter someone from a particular behaviour, it can
also produce some undesirable effects, such as:

 Impacting on the relationship, as the person may begin to dislike the punisher
 Can be perceived by the person as 'attention' and have the opposite effect
 Does not teach desirable behaviour

Classical conditioning

Russian scientist Ivan Pavlov made a historical discovery around 1900 whilst conducting his
classical conditioning experiments with dogs. Classical conditioning (sometimes known as
Pavlovian conditioning) refers to situations where automatic reactions become elicited by
conditioned stimuli, in addition to the unconditioned stimuli that normally elicit them.

Pavlov's famous experiment

Initially, Pavlov was interested in the salivary secretion created by dogs and developed
procedures to measure the amount of saliva created. He tested them on successive days
and found that dogs that had been through the testing procedure several times would begin
to salivate before the food was even presented. Pavlov concluded that the dogs were
showing signs of learnt behaviour. The salivation, which was initially an automatic response
to the stimulus of food, was now elicited by a new stimulus, perhaps the clicking sound of
the device that produced the food. To investigate this further, Pavlov began to pair the food
with various stimuli, including a bell. After the food and bell had been presented together
several times, the dogs began to associate the bell with the presentation of food and would
salivate. When the bell sounded without food being present, the dog automatically
salivated. So what began as a neutral stimulus – a bell – was now the trigger for salivation.

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 Centre of Excellence Online – Cognitive Behavioural Therapy (CBT)

Terminology

The classical conditioning terminology can be a little confusing at first, so below are the
definitions of each term and then an example of how they are all linked together.

Unconditioned stimulus is something that obtains an instinctive response, for

example, the food.

Unconditioned response is the instinctive response that is obtained by the

unconditioned stimulus, for example, the salivation.

Therefore, the food naturally produces drooling in a dog.

Conditioned stimulus is something neutral that develops the capacity to obtain a

conditioned response after it is paired with an unconditioned stimulus, e.g. the bell.

Conditioned response is the response obtained by a conditioned stimulus after

classical conditioning has taken place, e.g. salivation.

What does all that mean? It means that the unconditioned stimulus (food) instinctively
elicits the unconditioned response (dog salivates). When the conditioned stimulus (bell) is
paired with the unconditioned stimulus (food), it creates a conditioned response
(salivation).

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Classical conditioning = when the conditioned stimulus (bell) can create a conditioned
response (salivation in the dog), when it is no longer paired with the unconditioned stimulus
(food). So the dog salivates when he hears the bell, even if there is no food! The dog has
been trained to associate the bell with food.

Extinction occurs when the conditioned response tendency gradually wanes and disappears.

Little Albert experiment

Sometimes when a response is conditioned to specific stimuli, other situations may also
elicit the same response. This is known as stimulus generalisation. This is an adaptive
process, because we rarely come across the exact same situation more than one time. For
example, if a child was bitten or scared by a particular dog, as an adult that fear may
become generalised to all dogs.

Behaviourist, John B. Watson (1920) conducted the first significant study of stimulus
generalisation, in his renowned "Little Albert" experiment. Albert was an eleven-month-old
infant, who was initially unafraid of a living white rat. When the white rat was presented
simultaneously as a loud, startling sound, Albert showed signs of fear in response to the
loud sound; and after seven united presentations of the sound and the rat, he also
experienced fear of the rat.

In this experiment, the CS (conditioned stimulus) was the white rat and the UCS
(unconditioned stimulus) was the loud noise. The CR (conditioned response) and the UCR
(unconditioned response) was the fear.

After five days, Albert was exposed to other stimuli that resembled the white, furry rat.
They discovered that the infant's fear response was generalised to a dog, a rabbit and even
a Santa Claus mask.

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 Centre of Excellence Online – Cognitive Behavioural Therapy (CBT)

Unfortunately, the outcome of this experiment on Albert's experience of white, fluffy

animals and objects is unknown, for the experimenters were unable to undertake the
extinction process to eliminate his fear.

Of course, with today's much stricter research ethics code, an experiment like this would
never come to light in contemporary psychology. However, Watson's mark on the
psychology of learning and his discovery of stimulus generalisation phenomena has had
effects that remain to the present day.

In contrast to stimulus generalisation, researchers also discovered stimulus discrimination,

where a person or animal has learnt a response to a particular stimulus and does not
respond in the same way when presented with similar stimuli.

Theory to practice

Classical conditioning plays a role in explaining phobia, an irrational fear that is intense and
persistent, and corresponds to an avoidant reaction. The most common phobias involve
heights, closed-in spaces, animals and blood.

Keeping with the dog theme, the example of a dog phobia will be used. Sally was bitten by a
dog one year ago. This experience was very scary for her and now when she sees a dog, she
becomes very anxious and will avoid going near it. Sally has generalised her fear of one dog
to all dogs. This is an irrational fear as not all dogs bite people.

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 Centre of Excellence Online – Cognitive Behavioural Therapy (CBT)

Assessment 1
Review of Key Ideas

Write a half-page response to each of the questions below.

Q1. How do the two schools of thought – cognitive psychology and behavioural psychology
– work together to form CBT?

Q.2 Explain in your own words why you believe thought processes influence feelings.

Q3. Explain the difference between classical conditioning and operant conditioning.

Mini Quiz

Q1. CBT was pioneered by:

a) Dr Skinner
b) Dr Pavlov
c) Dr Beck

Q2. CBT is based on the premise that:

a) Thoughts cannot be changed

b) Altering thought processes can alter behaviour
c) Situations, not thought processes, affect feelings

Q3. A positive reinforcer is...?

a) Something that is added to strengthen behaviour

b) Something that is removed to strengthen behaviour
c) Something used as punishment

Q4. What is a conditioned stimulus?

a) An instinctive response
b) Something that is paired with an unconditioned stimulus to produce a conditioned
response
c) It's the same as an unconditioned stimulus

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