Behaviour therapy

  Behaviour therapy principles are about as different from psychodynamic psychotherapy as it is possible to be. They are based on learning theory which made a virtue of removing ‘consciousness’ from the equation – change is explained by reflex learning. Behaviour therapy is indelibly associated with B. F. Skinner who demonstrated that you could train rats in quite complex behaviours simply by rewarding the behaviour you wanted (‘operant conditioning’) or, alternatively, ‘punishing’ the behaviour you wanted to stop. Behaviour is ‘shaped’ in small steps, one at a time. The unique aspect of behaviour therapy is that it is irrelevant whether the subject agrees or even knows what is going on – the learning is completely unconscious.

  Behaviour therapy can be staggeringly effective – think how easy it is to ride a bike and yet you probably have never ‘consciously’ learnt. You just tried it and each time it started to go wrong your body compensated, and now you are supremely skilled. Behaviour therapy works like that. It has proved particularly effective in treatments for individuals with learning disabilities and with children. A simple example of operant conditioning is the bell-and-pad system for nocturnal enuresis (bed wetting). A bell rings as soon as the pad gets wet, waking the patient. Over time he starts to wake up when his (it is usually his) bladder is full, as that sensation becomes associated with the bell and being woken. This successful treatment is widely used despite contradictory beliefs that bed wetting is either evidence of neurotic problems or, the opposite, that it is predominantly genetic.

  Behaviour therapy is extensively used for phobias and for obsessive compulsive disorders. The patient is gradually exposed to the feared stimulus (e.g. a dirty hand for someone with obsessions about germs) while restricting avoidance and monitoring anxiety to ensure it remains tolerable. In practice behaviour therapists still take detailed histories because, without a good therapeutic relationship, patients drop out of treatment.

Cognitive behavioural therapy

  Cognitive behavioural therapy could be considered a sophisticated extension of behaviour therapy, although it could also be viewed as an adaptation of psychodynamic psychotherapy. It lies somewhere between the two. It was developed by an American psychiatrist, Aaron Beck. He was a psychoanalytically trained psychiatrist who found a proportion of patients did not benefit from his psychoanalysis. On the whole they were people who valued mastery of their symptoms more than understanding them. His exploration, particularly of depression, convinced him that it was unconscious and pathological thoughts as much as feelings that were trapping his patients. He developed a therapy to enable patients to identify ‘automatic negative thoughts’ (self-critical, self-defeating beliefs and conclusions) and to train them in how to challenge and contradict them.

  His method emphasized ‘Socratic Dialogue’. Socrates believed that all you needed to teach truth was to keep asking the right questions and people found the answers within. Whenever the patient expresses a pathological doubt – e.g. ‘I got it wrong at work today. There’s no future for me’, the therapist asks them to explain it – ‘Explain to me why there is no hope.’ He contrasts the thoughts with the reality of the situation – ‘Explain how it is that you’re still being promoted at work then, despite these mistakes?’ CBT is now an essential part of psychiatric practice and training and is a standard ingredient in the treatments of depression and anxiety. It is also being increasingly used in a whole range of disorders including schizophrenia with intractable hallucinations or delusions and also physical disorders with a significant psychological component.