Cognitive behavioural therapy has become one of the most popular forms of contemporary psychological therapy, rising into fashion in the latter 20th century in the 'cognitive revolution', overtaking the psychoanalytical practice championed by Freud.
The History of CBT Cognitive Behavioural Therapy
Pavlov’s dogs salivating at the sound of the dinner bell; Skinner and his rats and pigeons in boxes learning to bring food down the chute by knocking a lever; Watson’s ‘little Albert’, the baby who learned to develop a fear of fluffy white objects after being frightened by a loud noise – all these behavioural experiments from the start of the 20th century have passed into our cultural history.
This early experimentation went on to inspire a form of therapy called ‘behaviour modification’ which was applied—more often than not, unsuccessfully—across a range of conditions, including addictions, ADHD, and even autism.
New ways of thinking
Following this, cognitive therapy emerged in the middle of the last century, partly as a result of advances in understanding of the way the brain and the mind function neurologically and biochemically, and partly due to the frustration of many researchers and therapists with the limitations of the prevalent therapies of the day.
This was a reaction to the work of Freud and his followers, who saw conditions that we would now call anxiety or depression as expressions of deep-seated neuroses, linked to unconscious memories and emotions. Instead, the cognitive therapists were more interested in the conscious mind in the present. They got their clients talking about their beliefs and habitual ways of thinking, and helped them to challenge fixed problematic ideas by looking at themselves and their situation in new, more adaptive, ways.
Aaron Beck, founder of cognitive therapy, famously told the New York Times about his falling-out-of-love with the psychoanalysis he trained in: “[I] found work with patients exhausting, because the goals seemed so unclear.The idea was that if you sat back and listened and said ‘Ah-hah,’ somehow secrets would come out… you would get exhausted just from the helplessness of it.”
Dealing with the here and now
So, CBT can be viewed as arising from two distinct (and in many ways opposing) schools of psychology: behaviourism and cognitive therapy. Where behaviourism rejected so-called ‘mentalistic’ concepts like thoughts and cognitions, relying instead on ‘observable processes’, CBT later grew to combine these elements together in its theory and practice, with great success. Although each stems from a different tradition, they both concern themselves primarily with what’s happening now to this client, and what this client experiences and believes and feels, at this present time.
“The sense of mastery from solving one problem frequently inspires the [client] to approach and solve other problems that he has long avoided. Thus, a bonus of successful therapy is not only freedom from the original problems, but a thorough psychological change that prepares him to meet new challenges.” Aaron Beck, 1979
This kind of brief, present-tense therapy is very different to the psychodynamic / psychoanalytic approach inspired by Freud, where traditionally, you might see your analyst, Woody Allen style, a few times a week over a period of years.
The evidence for CBT
Due to its experimental support and therapeutic successes, CBT had become widespread by the mid-90s, and today in the UK it is promoted by the NHS (as recommended by the National Institute for Clinical Excellence), and often in the media, as the most effective and efficient form of therapy available.
This attention is due in most part to CBT psychologists having made it their business to prove the effectiveness of CBT. Hence many more clinical trials have been conducted in recent years around CBT than for any other form of therapy, and it boasts a strong evidence base across a whole range of emotional issues, from anxiety and depression, through to food-related issues such as anorexia and bulimia, as well as trauma, insomnia, anger and OCD.
What we must bear in mind though, is the effect that the ‘fashion’ of a certain therapy has on the subsequent funding for its research, and the volume of psychologists interested in carrying it out. CBT is enjoying great success in both these respects; with public health backing in the UK, there are a large group of psychologists working on proving its efficacy, and relatively large sources of funding to help them do this.
However, there is growing evidence that many other forms of therapy—including existential therapy, schema therapy and systemic therapy—counselling psychology, mindfulness-based and integrated approaches may be just as effective as CBT.
Some researchers even suggest that, faced with a selection of therapies that may be roughly equally effective in helping people, the important variable that sets them apart is the therapist. In essence, a therapist who is able to form a successful therapeutic alliance with their client is more likely to help them towards positive change in their lives, no matter what theoretical basis underpins the work.
The strength of the relationship between client and therapist is clearly very important here, but so too is a belief shared by client and therapist . . . that this style of therapy, as opposed to that, is the one best suited to this situation and to this client.
‘Third wave’ cognitive behaviour therapy
If strict behaviourism was the first wave, and cognitive therapy the second, what’s now referred to the ‘Third Wave’ of CBT is relatively new, though it has developed more strands and refinements over just the past five to ten years.
The emphasis now is not so much on rationally contesting maladaptive thinking patterns, but on developing a posture of mindfulness in relation to ones thoughts and emotions—seeing them as transient events that are happening to us, rather than as absolute truths in their own right; noticing ones emotions rather than fighting them; observing ones thoughts rather than getting caught up them.
As ever acronyms abound in modern forms of therapy! and so branches of this ‘third wave’ include Mindfulness Based Cognitive Therapy (MBCT or M-CBT) and Acceptance & Commitment Therapy (ACT). See this article on our website for a discussion of these mindfulness-based therapies: An overview of mindfulness-based therapies.
It’s often said that CBT owes a debt to the Roman philosopher, Lucius Seneca, who was convinced that people suffered unnecessarily not because of their situation, but because of their thoughts about that situation, and in particular fears about their future. He also reckoned that changing ones behaviour and taking action was the most powerful means of dispelling negative thoughts. Here’s a handful of quotations giving a flavour of his philosophy:
“It is not because things are difficult that we do not dare, it is because we do not dare that they are difficult.”
“We are more often frightened than hurt; and we suffer more from imagination than from reality.”
“True happiness is to appreciate the present without anxious dependence upon the future.”
“Fear keeps pace with hope. Nor does their so moving together surprise me; both belong to a mind in suspense, to a mind in a state of anxiety through looking into the future. Both are mainly due to projecting our thoughts far ahead of us instead of adapting ourselves to the present. Thus it is that foresight, the greatest blessing humanity has been given, is transformed into a curse. Wild animals run from the dangers they actually see, and once they have escaped them worry no more. We however are tormented alike by what is past and what is to come. A number of our blessings do us harm, for memory brings back the agony of fear while foresight brings it on prematurely. No one confines his unhappiness to the present.”