Motivation and emotion/Book/2020/Cognitive behaviour therapy and emotion

Overview
According to the Royal College of Psychiatrists in 2009 Cognitive behavioural therapy (CBT) is one of the most effective treatments for conditions where anxiety or depression is the main problem as it can help patients break the vicious cycle of altered thinking, feeling and behaviour. CBT is the treatment of choice within the NHS (England based national health service) for depression and was developed by Beck in the early 1960s who found that it can be as effective as antidepressants for many types of depression. CBT can have positive effects on people's emotions by changing the way in which they perceive the events around them, it's framework mainly relies on participants developing a strong professional relationship with their psychologist to allow for fortnightly sessions that are based around the participant coming to terms with the things that are currently happening around them.

This book chapter focuses mainly on the emotions of individuals who have mental health issues like depression and anxiety due to the amount of overall empirically accepted research on these issues compared to other mental health issues.

Focus questions:
 * Why is CBT important in emotions?
 * How can we examine the effects that CBT has?
 * What are the practical applications of this chapter?

Cognitive behavioural theory
Cognitive behavioural theory focuses on changing unhelpful or unhealthy thoughts and behaviours. It is a combination of two therapies: ‘cognitive therapy’ and ‘behaviour therapy’. The basis of both these techniques is that healthy thoughts lead to healthy feelings and behaviours (Plate, Aldao 2017). Cognitive therapy is an intensive short-term psychotherapy which focuses on how patients make use of the information at hand in arriving at idiosyncratic interpretations and the effects of these views on their emotional experience. Many of the interventions in cognitive therapy set a goal of trying to “take a step back from” or to “distance themselves from” their thinking so that new information can be considered. Whereas behavioural therapy aims to teach the person techniques or skills to alter their behaviour. Cognitive theories of emotion have shown that there are a number of ways in which emotions can be influenced. CBT is important in emotions due to the nature of the therapy itself, by having a psychologist work closely with the participant it forces a conversation where reality has to be noticed by the individual. Beck realised the link between thoughts and feelings was important as he developed CBT, he invented the term 'automatic thoughts' which described emotion-filled thoughts that might pop up in the mind. In Beck's study he found that people weren't always fully aware of these thoughts and most of the time when negative thoughts occurred they weren't realistic or helpful.

How CBT works:


 * 1) First the automatic thought is identified
 * 2) Then the validity of the automatic thought is questioned
 * 3) Finally this challenges the core beliefs that the patient has

In Freeman and Powers' 2007 review they stated that there have been numerous randomised clinical trials that support the efficacy and effectiveness of CBT for depression across a variety of clinical settings and populations (Clark, Beck & Alford 1999; De Rubeis & Crits-Christophe 1998; Dobson 1999; Robinson, Berman & Neimeyer 1990). - New title; Criticisms of CBT. Critics of CBT argue that because the therapy only addresses current problems and focuses on very specific issues, it does not address the possible underlying causes of mental health conditions, such as an unhappy childhood (NHS Choices, 2010). Other criticisms of CBT include clients who have a problem with overintellectualising or those with minimal intelligence result in lower effectiveness. Weiner, Freedheim and Stricker in 2003 point out that “although the scope and efficacy of CBT are impressive, much work needs to be done. In particular, future efforts of CBT clinical researchers must demonstrate the effective of treatments outside research centres as well as turn more attention towards disorders overlooked by CBT (e.g., personality disorder)." Other criticisms lie in the strict framework in which CBT operates on which doesn't always allow for the resolution of underlying issues. From the psychologists' perspective CBT has been reported as a source of boredom and burnout as clients who refuse to face the reality around them from overintellectualising or other means end up repeating the same arguments with the therapist as the therapy loops in circles without any progress. Cognitive behavioural therapy (CBT) has been shown to be an effective treatment for depression and panic disorder in many randomized controlled trials (Gloaguen et al.,1998; Gould et al., 1995) However, more recent research has displayed that additional studies are needed to clarify the role of emotion regulation in CBT for panic disorder given the absence of such studies to date. However, findings from studies examining the role of emotion regulation in CBT for related anxiety disorders can serve as a basis for forming a hypothesis. For example, studies have shown that reappraisal increases in CBT for social anxiety disorder and that these increases generally predict subsequent reductions in anxiety symptoms, though findings regarding suppression are less conclusive (Goldin et al., 2014; Moscovitch et al., 2012).

Anxiety
Cognitive models of psychopathology tend to emphasise the role of dysfunctional thinking patterns in the development and maintenance of emotional disorders. Anxiety is a well researched mental health issue, the cognitive profile in the anxiety disorders is characterised by future-orientated automatic thoughts about potential physical or psychological threats or danger (Beck & Clark, 1988). Symptoms of anxiety disorders are usually divided into somatic and emotional symptoms. Somatic signs are manifested by abnormal bodily reactions such as rapid heart rate, muscle tension and excessive sweating. Successfully engaging in a pleasant activity may serve to enhance one’s expectancies for change. For example, anxiety and depression are often associated with poor social skill performance or performance on cognitive tasks due to this symptoms of anxiety disorder are often misinterpreted by more serious ailments (Shear, 2003). Treatment from the cognitive behavioural perspective assumes that anxiety is a normal, expected emotion comprised of biological, behavioural and psychological components. Individual risk for anxiety disorders vary given an individual’s genetic predisposition, temperament, family history, learning and environmental experiences, parenting styles, and other endogenous and exogenous factors. In its adaptive or ‘normal’ form, anxiety serves a protective function for the individual to alert him or her to danger and/or to motivate certain adaptive behaviours to avoid stress or negative experiences (Albano et al., 2009). CBT for childhood anxiety disorders has emerged as an efficacious psychosocial treatment approach (Albano et al., 2009).

Depression
Basic cognitive research has suggested that negative mood states are likely to lead to biases in attention, less efficient processing of information and poorer memory for mood-incongruent information, or perhaps selective memory for mood-congruent information. These findings are supported in clinical applications, impairments in attention, concentration and memory are frequent complaints of those suffering from anxiety disorders and depression. Clinical observations are full of examples of the ways in which reported events and their interpretations appear to be negatively biased. As in the lab (Bargh & Tota, 1988; Gotlib, McLachlan & Katz, 1988; Mogg et al., 1991), patients often report negative perspectives to their therapists in a fashion that is automatic and apparently without an awareness that there might be alternative point of view. Much of the work in CBT is designed to break the automaticity of negative thoughts and assumptions. Depression is another mental health issue that has been well researched. CBT is recommended by the Australia and New Zealand clinical practice when dealing with depression. Depressed individuals tend to be more self-focused or self-conscious than those who are not depressed (Ingram & Smith, 1984). Several theorists have argued that the tendency to self-focus, rather than engage in active coping may influence the course of depression (Ingram,1990; Lewinsohn et al., 1985). There has also been considerable research which demonstrates the difference of cognitive content between depression and the anxiety disorders when a tendency to self-focus is developed when the content of automatic thoughts is predominantly negative, stressing past losses and failures (Beck, 1967) depression is much more likely to occur. For example, a depressed individual tends to interpret personally negative experiences as evidence to support the view of oneself as a failure.

Medications such as antidepressants are effective for low/ mild cases of depression, when used in conjunction with CBT the rates of relapse or dependence are decreased. In severe depression it's recommended by the Royal College of Psychiatrists (2000) to use antidepressant medication in order to begin therapy after beginning to chemically change the way that the patient thinks.

Case study
Noluthando is a South African adolescent girl who was 17 when introduced to psychotherapy, she came from a problematic family home with an alcoholic mother and an abusive father to his mother. In Noluthandos mind she struggles to remember a time where neither of these problems existed. Noluthando was referred to a psychology clinic by a school counsellor after she had attempted suicide in late 2009. In a self-report, Noluthando felt that she was performing well at school and while there were problems at home she felt that she was coping in the earlier parts of 2009. Towards the end of 2009 Noluthando’s abusive father was diagnosed with HIV and this event reminded her of how her family doesn’t communicate effectively and the overall negative relationship between them.

Noluthando had problems with displaying her emotions and set a goal of wanting to open up to people through CBT. There were communication issues from her early childhood. These issues made opening up for CBT difficult, as the therapy was slowly implemented the therapeutic relationship flourished and became more collaborative. Importantly this collaboration empowered Noluthando to take responsibility for her own therapy and improve her mood.

Easterbrook and Meehan (2017) as the therapists from the study commented on how CBT was more effective when the framework wasn't strictly followed but served rather as a guideline in which it was applied successfully.

Practical applications


CBT has also been successfully used to treat many clinical conditions such as:
 * Gambling addiction
 * Substance abuse
 * Insomnia
 * Personality disorders
 * Psychosis
 * Stress management
 * Depression
 * Anxiety

Cognitive approaches emphasise the role of thought in the development and maintenance of unhelpful or distressing patterns of emotion or behaviour. Treatments for anxiety and depression often begin with assignments for self-monitoring of critical events (Beck et al., 1979; Beck & Emery, 1985). Due to the flexibility of CBT it can be delivered in individual, group and couple formats.

In practical applications of CBT monitoring can direct attention to the positive events that do occur which helps when avoiding recall biases often present in retrospective reports and can provide a more accurate/complete picture for therapist and client. Writing down one’s thoughts when experiencing negative emotions may help to slow down the process of thinking about and evaluating circumstances. Monitoring of variations in mood and cognition can also serve to reinforce the rationale and credibility of CBT by providing a first-hand demonstration of the correspondence between one’s mood and interpretation of events. This can lead to the breaking of the automatic habitual pattern of assumptions which lead to and contribute to maintaining negative mood states. Another technique which has practical applications from CBT is activity scheduling where a patient is encouraged to schedule and engage in simple time-limited activities which are enjoyable which helps facilitate efforts to consider alternative perspectives and encourage active coping.

How does CBT effect emotion practically?
The evidence supporting CBT informs us that as a theory it does have practical applications, the skills you learn in CBT are practical and helpful strategies that can be incorporated into everyday life even after the treatment is finished. Fundamentally the focus of CBT is to identify how problematic feelings are affecting their patients. CBT has the research behind it which has shown that it has the power to positively effect emotion by having solved a wide range of negatively charged emotional conditions like depression, anxiety and different types of addiction.

Quiz
{Which of the following mental health issues can be affected by cognitive behavioural therapy - Depression - Anxiety - Hypochondria + All of the above
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Conclusion
CBT has many real-life applications and has been regarded as a theory supported by multiple counts of empirical evidence spanning over several decades. For future directions of research more research could on different psychological disorders like dissociative personality disorder, schizophrenia and even areas of psychosis still need to be further researched in order for CBT to be considered the standard at which all therapy should begin with.