Chapter ten

The wider application of cognitive therapy: the end of the beginning

J.Mark G.Williams and Stirling Moorey

Let us begin this final chapter by picking up a theme which Professor Beck alluded to in the foreword to the book. The application of a novel therapy to an area of clinical work needs to go through certain stages. It is as if the emergent therapy has a developmental history of its own, and is bound to a time course. Such a time course can be observed to have occurred in the application of systematic desensitisation to phobic problems, the application of social skills training to assertiveness problems, and the application of cognitive behaviour therapy to depression. It involves showing, first, that the therapy can work with individual case examples; second, that it does work with a group of such cases in a clinical series; third, that it works better than control conditions in a properly controlled clinical trial. When this has been achieved, two types of question then follow: (1) how does the therapy work in the conditions where it is known to work (e.g. cognitive therapy with depressed patients); and (2) can the therapy be applied to other clinical conditions outside the original domain in which it was developed. It is this second question which has been addressed in this book. Each potential application of the technique will have its own developmental stages to go through, beginning with uncontrolled case studies. Most of the work presented in this book is at this early stage, but this does not prevent us from learning a great deal which can contribute to our work as clinicians or teachers or researchers.

In this final chapter we should like to do four things: (1) to summarise some themes that have emerged from the case material presented in the book; (2) to discuss what other client groups cognitive therapy might be relevant to, and to discuss in more detail its application to people who have learning disabilities; (3) to discern the framework within which cognitive therapists appear to be working and to make it explicit; and (4) to describe some future strategies for research, both fundamental and applied.

Emergent themes

Cross-sectional and longitudinal assessment

Cognitive therapy has often been called a ‘here and now’ therapy. To a large extent this is true. Session by session, examples of difficult situations are taken from the previous week. Tasks are assigned as homework specifically to create the day by day conditions where more data will be gathered to test out the reality basis of attitudes, thoughts, and images.

But what also emerges from looking at the practice of cognitive therapy is the importance of setting the present in the context of the past. This is especially true in the initial assessment where both long-term developmental issues relating to childhood and adolescence and shorter-term issues surrounding the onset of the current problems are discussed. But how should these data be gathered? Let us look at one or two of the therapists at work in this book to see if any pattern emerges.

Blackburn (Chapter 1) is quick to ask where the problem started. But note that it is not just a series of facts that is being established by the therapist. She takes seriously the opinions, attitudes, and evaluations expressed by the patient about the details they are describing. For example, when the patient describes having been passed over for promotion, the therapist asks how it made the patient feel (p. 6) and then goes on to point out to the patient the distinction between thought and feeling. Similarly, when the patient says of her work arrangements ‘I did not know what was going to happen to me’, rather than merely concentrating on getting the bare facts (in which case the next question would have been “And what did happen?’), Blackburn asks ‘What did you think could happen to you?’ (p. 7). Note that information about the history of cognitive symptoms is here being gathered alongside the ‘factual’ material. This, of course, appropriately reflects the nature of the development of symptoms: ‘fact’ is rarely separable from interpretations and feelings that surround events. Interpretations and feelings have consequences for subsequent events and subsequent behaviour. This, then, illustrates an important aspect of assessment in cognitive therapy. As well as cross-sectional (here and now) assessment, there is the need for longitudinal assessment. The development of the current episode and the case history over a longer time period are relevant, but bare ‘facts’ are of little use. What the cognitive therapist requires are the interpretations and feelings surrounding the

130 COGNITIVE THERAPY IN CLINICAL PRACTICE

autobiography. When this is done, interesting patterns may emerge. Note Greenberg’s (Chapter 2) observation of similarities between patients’ attitudes towards their symptoms and their outlook on other problems (e.g. ‘This means I am defective and can’t handle things’, ‘Problems always get worse and they last for ever’—p. 28). However, also note how she feels that it is very important with the particular patient she discusses not to try to deal with basic attitudes (which have grown up over a lifetime) too early in the therapy.

Engagement in and explanation of cognitive therapy

Our experience of running training workshops in cognitive therapy teaches us that this aspect is one of the most difficult. People ask ‘How do you introduce the cognitive model?’ How do you begin to get the person to look at their ideas as just that: ideas. Let us look at what the therapists in this book do.

Blackburn (p. 61) in listening to the patient’s history asks of an event: ‘How did that make you feel?’ The patient’s reply includes ‘I must be inferior’. The therapist responds ‘That’s what you thought, but what were your feelings, can you remember?’ From early on, Blackburn is making a distinction not didactically, but as part of the questioning and clarification.

Greenberg’s patient was nervous when driving into work. He describes ‘a nervous state, a feeling of like, “I don’t know whether I want to stay here or if I want to go”’. The therapist replies, ‘You had automatic thoughts like “I don’t know whether I want to go or stay at work”?’ Note again, the therapist makes a distinction between feelings and thoughts, not explicitly, but by gradually introducing the distinction into the vocabulary she uses to ask the questions and reflect back what the patient says.

Salkovskis (Chapter 3) describes the engagement of an obsessional patient who began the first session in tears, finding it difficult to start discussing her problem (p. 59).

P: I shouldn’t really be wasting your time.

T: It sounds like you had a really upsetting thought just now. P: Yes.

T: What went through your mind right then?

P: I thought that I must be a very bad patient because I can’t tell you about my problems.

T:Well, it’s interesting you should say that, because it seems to me that you have just told me one of your problems; I mean that you have a problem talking about your difficulties.

P: Yes, but that’s not my real problem.

Salkovskis uses the first thing that happens in therapy, the apologies and the crying, as a way of gently introducing the cognitive model. But again this is not done explicitly or didactically.

These examples give us a good indication of how the engagement in this particular form of therapy is achieved. The very style of questioning is the key. When people relate facts, they are asked about their interpretations, their thoughts, their feelings. When they make a statement about themselves, the statement is reflected back but only after having been gently placed within a cognitive framework. The therapist’s style thus becomes a model for the patient—a model in which a structured, active, discriminating, questioning approach is substituted for an unstructured, passive, global, declarative approach that many such patients commonly use in their emotional lives. Only when this is under way is the model explicitly and more didactically introduced. Of course, there are exceptions to this sequence, but even so the method of engagement in therapy is similar—questions of clarification which implicitly reflect the cognitive framework.

Techniques for eliciting thoughts and feelings within the session

The variety of techniques for eliciting thoughts and feelings during the session is very large and we can do little more than highlight one or two aspects in this summary. Direct questioning is one approach, and we have illustrated this in talking of the way in which a therapist attempts to engage the patient at the beginning of therapy. The above descriptions also illustrate another approach: using times when the patient appears upset to ask what went through their mind just then. This was a technique that Salkovskis used at the beginning of the therapy session he describes. But a technique which emerges very clearly in some of the case descriptions in this book is the introduction of behavioural experiments within the session to simulate real-life circumstances. For example, Greenberg uses the hyperventilation technique to examine the patient’s thoughts and feelings about their own bodily symptoms. After hyperventilation for two minutes the patient reported discomfort: sweating, drowsiness, stinging, apprehension. He also reported the fear that he was going to faint. This in turn reminds him of the feeling that he gets outside the therapeutic situation in which he finds himself asking the question, ‘Can I get help?’ or ‘I’m all alone here, could I get to…?’ and ‘If I died what would happen?’ and ‘Well, who would care?’

In Channon and Wardle’s description of their patient with an eating disorder (Chapter 6), they demonstrate the use of a behavioural experiment (eating a small piece of chocolate) to elicit automatic dysfunctional thoughts. The patient was asked

THE WIDER APPLICATION OF COGNITIVE THERAPY 131

to list her thoughts at four stages: (1) before the food is presented; (2) in the presence of food, before eating; (3) during eating, and (4) after eating. The statements that the patient made were at first fairly specifically related to the chocolate itself: ‘Chocolate is unhealthy’; or fairly closely related to the patient’s own lack of impulse control: ‘If I have one bit I’ll go on and on eating’. But these thoughts were able to form the basis of further exploration so that the therapist could ask what the patient meant when she said that chocolate was unhealthy. Once again, the patient’s attitude seems unremarkable: ‘Everyone knows that chocolate is fattening’. It is not clear that there is very much that is dysfunctional here until the therapist gently pushes a little harder and finds that the patient believes that simply having eaten the small piece of chocolate will make her fat because it just sits in her stomach. The therapist asks about the consequences of this and the person replies, ‘It’ll just stay there and I’ll have a great big stomach and get fat.’ Note the therapist’s reply to this (once again in the form of a question, and once again using the vocabulary of cognitive therapy so that the point is introduced gently): ‘Is that a very frightening idea for you?’ Patient: ‘Yes —I’d hate myself and look ugly.’

In Moorey’s description of the treatment of drug abuse (Chapter 7) we find another example of using exposure to a specific situation to assess the dysfunctional aspects. Tables 7.3 and 7.4 in his chapter reproduce the stimuli that were used in an exposure situation within the session. A picture of a doctor’s surgery, a tourniquet and a spoon, an empty syringe, a syringe and needle, syringe and needle containing physeptone, drawing up drug from an ampoule, finally sitting with syringe and needle against the arm. Note how this situation differed from the sort of exposure that might be used in behavioural therapy without a cognitive component. In Moorey’s case, the exposure was presented as an experiment in which the subject tested out her prediction that in the presence of the stimulus her craving would not reduce. In fact the craving did reduce over time and the therapist was able to point out the extent to which the patient was using active strategies in coping with her craving. As the craving reduced so the automatic thoughts that were recorded changed in nature from ‘I’d enjoy a fix’ and ‘The heroin looks familiar and comforting’ at the point at which craving was at the highest, to ‘I can’t wait to throw this heroin away’ at a point when the craving had reduced.

Cole (Chapter 8) gives several examples of the use of imaginal cognitive rehearsal of specific offence situations to elicit the thoughts and feelings of people undergoing cognitive therapy for offending behaviour. A client awaiting trial for indecent assault on male teenagers was helped to recall one of the incidents. The therapist asks what he noticed about a particular imagined young male. When the client replied, ‘He’s smiling at me’, the therapist asked how he was feeling right now. The client replies, ‘Sort of friendly and affectionate.’ The therapist is then able to ask what it meant that he was smiling at him? The client replies, ‘Children are attracted to me. They come straight towards me. I’m popular.’ Cole uses this material to derive as comprehensive a hypothesis as possible about the setting conditions in which the offending behaviour occurs and what is maintaining it. Making these issues explicit to the client can then lead to mutual decisions as to what behavioural experiments can be done to test out (within or between sessions) the factors which are involved in their behaviour.

Dealing with dysfunctional attitudes

Making explicit dysfunctional attitudes is a theme common to all the cognitive therapy strategies which have been illustrated in this book. These are sometimes directly related to the ‘symptoms’. For example, the exhibitionist mentioned by Cole who said, ‘I am over-sexed. I have stronger feelings than other boys so I have to do something about it.’ But Cole also points out how closely related this is to a feeling of dependency. This means that the client not only believes that he cannot overcome his propensity to continue with offence behaviour but also believes he cannot cope in life without the help of others. His feeling of need of help may exceed the resources he needs to enable him to stop. This can jeopardise the formation of reasonable goals and maintenance of change as a result of therapy.

A similar self-schema is illustrated by Moorey in his description of drug abusers: ‘If I get a craving I have no control over myself; ‘I’m too weak to control myself’. But the other side of the dichotomous thinking is also represented in their assumptions: ‘Getting over drugs is something I have to do without any help from anyone.’ Moorey’s description of the selfschema of Ted on p. 178 shows how a person’s attitudes and behaviour can be closely interrelated. Note also the example of Jane on p. 178 to whom heroin provided a way of integrating a number of assumptions she had about herself into a stable schema which ran something like this: ‘I am a sensitive, intelligent, and romantic individual who cannot stand the harsh real world without heroin to deaden the pain.’

Cognitive therapists use a variety of methods to assess underlying attitudes. One common method is to use a questionnaire such as the Dysfunctional Attitude Scale (Weissman and Beck 1978). This yields a score, but perhaps more valuable than that, it can form the basis of a discussion with the patient within a session and the basis of patient’s own thought catching outside the session. In a second technique to help between-session thought catching, the patient can be asked to look out for the occurrence of ‘shoulds’, ‘musts’, and ‘oughts’ in their daily life. Often when these words occur, there will be a general belief lying ‘below the surface’. The patient can then try to practise discerning what these beliefs are, and to what extent they are maladaptive.