The ABC of CBT CAT RET DBT

Not an excerpt from my DNA, but Cognitive Behaviour Therapy and some of its variants - Cognitive Analytic Therapy, Rational Emotive Therapy and Dialectical Behaviour Therapy.

CBT is predicated on the assumption that thoughts cause emotions, and thus negative emotions are the result of negative or irrational thinking or beliefs, which are often long-standing and all-pervasive. CBT and its variations are considered to have several practical merits - that they are benign, evidence-based and time-limited (and hence relatively inexpensive). Assertions of their benignness are reasonable enough - they carry neither the physical risks of medication or the psychological risks of the analytic therapies.

One of the earliest forms of CBT was Rational Emotive Therapy (RET), formulated by irascible Albert Ellis, who's not interested in your childhood (even though he had a less than pleasant one), but nevertheless expects you to do your homework. Influenced by the Stoics, he opined that events and emotional responses are fundamentally causally unrelated, with emotional reactions due not to the events themselves but to our (presumably pathological) beliefs, interpretations, and philosophies of and about those events, particularly those concerning how the world should work. The proposed disjunction between events and emotions is similar to the Saussurian delineation of the relationship between the signifier and the thing signified, i.e that the signified (the animal that moos) bears no meaningful relation to the signifier (the word 'cow').

The RE therapist thus is expected to demonstrate to his or her clients how their absolutist modes of thinking about events lead to their distressing emotional reactions and how to question these modes, with the goal of replacing them with empirically testable modes of thinking that are less likely to make them miserable, a process known as reframing. The process that allegedly underpins depression or anxiety can be summarised as the ABC Technique of Irrational Beliefs:

A - Activating Event - an event that prompts distress,

B - Beliefs - the (negative) beliefs held about the event,

C - Consequence - the negative feelings and/or dysfunctional behaviors that follow.

Non-empirically testable beliefs include, of course, the notion that we have limited control over our emotions and that we cannot help feeling disturbed about certain things. This immediately highlights a significant problem with RET, or perhaps not with RET itself, but with attempts to apply it in certain cases. It is, I believe, a verifiable fact that some of us have less control over our emotions than others; that this is a developmental stage frequently encountered by those suffering from the aftermath of childhood abuse and trauma. This reality, combined with the practice of providing RET in in- or out-patient group settings, guarantees that RET will be offered to people to whom it is not only irrelevant, but potentially damaging. RET establishes a disputatious relationship between patient and therapist, which wouldn't be terribly helpful if the patient has had others constantly invalidating his or her perspective from an early age.

The other problem with RET is that it is ill-suited to those of a philosophical or analytical bent. It abounds with logical cul-de-sacs: " So, I shouldn't say 'shouldn't'? How does that work?", and the distinction between 'it should' and 'I would prefer' may seem a matter of semantics. And needless to say, if the disconnect between event and emotional response is taken to the extreme espoused by Marcus Aurelius... it would be a mighty strange world to live in, that's for sure. Anything goes, anything must go, because how you feel about me killing your children and burning your house down is your problem, babe.

And where do these self-defeating beliefs come from, by the way? Albert Ellis is willing to concede that childhood trauma and other environmental factors may play a part, but that it is secondary to that played by biological factors, which are presumably more salient in those suffering from emotional, social or behavioural problems.

Which takes us to Dialectical Behaviour Therapy (DBT), developed by Marsha Lineham to treat them darn borderlines (TDBs). I DBT I've ever had DBT, so it's hard for me to cast definite DBTs on its usefulness, so all I can do is offer a commentary, based on what are quite possibly DBTful sources, and offer my DBTful conclusions. I have no DBT that someone else could provide a more detailed and penetrating analysis.

DBT utilises many techniques common in CBT, such as self-monitoring, placing emphasis on the here and now, homework and diary-keeping between sessions and a the forging of collaborative relationships (the 'dialectic') between TDBs and their therapists. It is comprised of two essential components:

1. Individual therapy in which the therapist and TDB discuss issues that come up during the week, with particular emphasis on any episodes of self-injury and suicidal behaviour. Then, if the fifty-minute 'boundary' permits, they may also discuss therapy-sabotaging behaviours, and then less important stuff like quality-of-life issues and improving one's lot in general.

2. Group therapy in which TDBs learn to use four specific sets of skills: core mindfulness skills (a cool Zen way of being awake and alert), emotion regulation skills (identifying and managing emotions), interpersonal effectiveness skills (coping with conflict) and distress tolerance skills (for handling crises and accepting things as they are).

DBT posits that TDBs have an underlying biological deficit that inhibits their ability to regulate their emotions, which is then exacerbated by TDBs perceiving others in their environments as invalidating their thoughts and feelings. Note the obvious biogenetic red herring (that Occam's Razor would have little trouble amputating), followed by the insinuation that the sense of being invalidated is often merely a product of TDBs' paranoid little imaginations.

I find that taking as first priority the elimination of self-harm somewhat arbitrary, if not exactly puzzling. If playing noughts and crosses on their thighs with a bit of broken glass is the worst TDBs can do (cf. calling their shrinks at home late at night, I hate you, don't leave me, etc), why are they so unpopular? As unfathomable and distressing to the observer it may be, self-harm is actually a relatively practical and considerate way of self-soothing, in that it is usually a private act, involving little inconvenience to friends/family/enablers/dealers/co-dependents/whatever.

And while the emphasis on the 'here and now' might be a relief for some, but given that TDBs are disproportionately likely to have been sexually, physically or emotionally abused as children, others may experience it as a 'cop-out', 'blaming the victim', or just 'missing the point'. As Australian consumer activist Merinda Epstein put it, "The present clinical fixation on time limited interventions based on changing our ‘behaviour’ suits some but for many of us it can be an insult to both our intelligence and the depth of our pain."*

Finally, there's Cognitive Analytic Therapy (CAT), which is essentially a hybrid of CBT and analytical approaches, particularly object relations theory. It was developed as a short-term (16 session) therapy for use in the UK's National Health Service. Again, the financial advantages of this, particularly from the NHS's point of view, are obvious, and may or may not override any considerations of clinical efficacy.

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I personally have benefited from a fairly straightforward application of CBT - when I was 11. I was socially isolated, and it made sense for me to try to acquire the skills to change this state of affairs in the year before I started high school, which presented an opportunity for a fresh start. The psychologist taught me, firstly, to identify my 'moods', as well as the various thoughts that apparently precipitated them - "Nobody loves me, everybody hates me", and to consider the impact that they had on my approachability. The treatment was successful - I moved on to high school, where I managed to make a few friends and interact well with most of the others - but a year or so later, I was wondering why nobody seemed to be interested in why I had been socially isolated and subject to mood swings in the first place. (At least at that point, no one seemed to be claiming it was biologically based.) It is almost as if the success of the treatment depended on my inability to put my situation in a political context, thanks to the intellectual limitations imposed by being an eleven year old.

You probably don't have to be a kid to benefit from CBT - certainly, as an adult, there's been occasions when I've thought I don't care why I am like this, I just want it fixed before I drive myself and everyone else nuts. But if you think that your problems are primarily more practical or emotional in nature and cannot be resolved without reference to your past or presence circumstances, the application of CBT and most of its variants may feel superficial, judgemental and impervious to your individuality.

Anyway, here's my A-B-C theory of effective psychotherapy, cognitive, analytic, down-at-the-pub or otherwise:

Adapts to and integrates the patient's understanding of the origin of his or her problems

Builds trust as the therapist creates a space that involves validation of patient's perspective as well as putting forward alternative interpretations of events or emotions

Contextualises the patient's concerns to the degree that is most useful to the patient.

Is this 'evidence-based', i.e. would this work? (At least I think that's what that means.) How do we define the efficacy of a therapeutic approach - by its theoretical coherence? Or its cost-effectiveness? Or merely its compliance rate? But this is another can of worms entirely...

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*"Let’s face it! She’s just too f*****d” – the politics of borderline personality disorder. Paper presented at Lock 'Them' Up? Disability and Mental Illness Aren't Crimes Conference, Brisbane, Australia, May 2006.