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What Do Cognitive Approaches Have To Contribute To CAT?

Llewellyn, S. and Cooper, M., 2004. What Do Cognitive Approaches Have To Contribute To CAT?. Reformulation, Summer, pp.20-24.

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Introduction:
What do CAT therapists think of cognitive approaches?

A Snapshot
Do you think Cognitive Therapy (CT) has much to contribute to CAT? One interesting and intriguing response to telling psychodynamic colleagues about CAT is that they often comment that it is a cognitive therapy, while cognitive colleagues are equally sure to comment that no, it is a psychodynamic therapy. So we opened our paper to the ACAT conference in March 2004 by asking participants whether they thought that cognitive approaches were important to CAT. The overall response, from those ACAT members who were present, was that cognitive approaches do indeed have something to contribute. When asked, at the start of our talk, to rate whether cognitive ideas contribute to CAT theory and practice, on a scale between 0 and 100 (100 = maximum belief that, yes, they do have something to contribute), the mean rating given by 110 conference attendees was 66 (s.d. = 21), with a range between 20 and 100. Although some people clearly have a much greater belief in the ability of cognitive ideas to contribute to CAT, overall the baseline belief was relatively high. Bravely (or foolishly) we tried repeating this rating again at the end of our talk, but think we should interpret these second results with caution, because our instructions for doing the task on the second occasion appeared to confuse people (note, even well planned and carefully thought out research can go wrong!). However, for what it is worth, after the talk the mean rating was 65 (s.d.= 23), which may indicate something about what we said, but (and hopefully more likely) because of methodological problems, may show nothing of the sort. There was a slightly wider range of views after the talk; some people shifted one way, some another, and some did not shift from their initial belief rating at all. However, perhaps most intriguing of all, some very interesting comments were added by participants, such as “If I must increase my belief in CT, then I won’t”, while others drew a helpful distinction between theory and practice, which was not distinguished in the original question; i.e while theoretical ideas may be potentially useful, therapeutic strategies may not, and vice versa. Nevertheless, the small survey we did suggests to us that ACAT members are well aware of the importance of the role of cognitive approaches in CAT, which was we thought a good start (i.e. audience not overtly hostile to the topic), and a helpful context for our talk

The Conference Paper
The current paper, based on the conference presentation, aims to explore the relationship of CAT with cognitive approaches. It provides a very brief history of the “C” in CAT, and of the history and basics of cognitive theory and therapy and an overview of current and new cognitive approaches in CT. It then explores areas of difference and similarity between CAT and CT. It also addresses the question of what CAT might learn from cognitive approaches, and vice versa. Finally it concludes with some questions about future developments.

Historical perspectives

CAT
Quite obviously, as an integrative approach, CAT has its roots in the intellectual soil and Zeitgeist of its time, which has included ways of thinking about humans from systemic, cognitive and behavioural perspectives. So it is possible to detect the influence of ideas from a variety of writers even if some of these names don’t appear in early texts, and even if the influence of some was indirect. Important cognitive influences have probably included Beck’s cognitive theory of the emotional disorders (e.g. Beck, 1967), Seligman’s learned helplessness theory of depression (e.g. Seligman, 1974) and his work on attributions (e.g. Seligman, Abramson, Semmel and Von Beyer, 1979), and Bandura’s work on self efficacy (Bandura, 1977), as well as most obviously Kelly’s personal construct theory (Kelly, 1955).

CT
Central to early cognitive-behavioural therapy (CT) approaches has been the importance of goal setting, formulation, collaborative working, self-monitoring, and the notion that an account can be provided of internal and external processes which precede and accompany distressing behaviour or symptoms. CAT also makes use of these ideas, although it applies them in a rather different way. One key idea from cognitive (or basic schema) theory, not particularly central to CAT, is that there are at least three levels of cognition that are linked: i. core beliefs or schema which are absolute and generalised judgments about self, others and the world; leading to ii. underlying rules, or “if”/”then” statements that apply across several situations; leading to iii. automatic thoughts, i.e., momentary self talk which is situation specific. These are characterised in any particular individual by their own personal styles of processing information. For example, a wide range of characteristic information processing errors are typically present in automatic thoughts and underlying rules, while schema are typically maintained by processes which act to maintain, overcome (compensate for) or avoid the central beliefs associated with them. The cognitive approach further argues that focussing on these cognitions and cognitive processes is the most effective way of addressing distress. A useful distinction is now often made in CT between developmental and maintaining factors. Interestingly, however, cognitive theorists have only relatively recently turned to serious consideration of developmental factors, and in the past have instead concentrated on describing specific maintaining models for different disorders, to the neglect of both historical and also contextual issues. Indeed developmental factors are barely discussed in many early texts.

Current Approaches
Most cognitive therapists now work by adapting a cognitive model of a particular disorder, symptom or set of symptoms to specific clients, and will start by trying to link thoughts, feelings, behaviour and physiological experiences, and showing how they may operate as a vicious cycle (or series of vicious cycles) in a particular case to maintain the client’s difficulties and distress. Many of these models are diagnosis based, rather than dimensional in orientation. Treatment is based on a formulation which aims to be collaborative, and is structured, so it normally follows an agenda and is time limited. Socratic questioning is used, so that clients learn to modify for themselves any unhelpful thoughts, beliefs and assumptions, by asking pertinent questions of their thinking and its processes. Homework tasks and behavioural experiments (to test the validity of unhelpful cognitions) are set, and therapists aim to help clients become their own therapists in the future. Emphasis is placed on learning to learn. Standardised, disorder-specific measures are used to evaluate outcome, and individualised measures of cognition may be used to track changes across sessions.

Process issues such as the therapist-client relationship used not to be seen as particularly important, but this is now changing (e.g., Waddington, 2002) and there is a growing awareness of issues such as transference and counter-transference (Leahy, 2001). Therapists in the field are beginning to discuss issues such as the effect or impact that their own cognitions (sometimes termed “therapy interfering beliefs”) may have on a client’s treatment, and their own willingness, for example, to attempt specific intervention strategies with individual clients. Recent innovations with a link to developmental issues have included schema-focussed therapy (Beck, Freeman and colleagues, 1990) and a growing emphasis on early maladaptive schema (Young, 1990; Young, Klosko & Weishaar, 2003) or negative self beliefs (Cooper, Wells & Todd, 2004)) . Theory and treatment has also been extended to new areas including psychosis, trauma, abuse, eating disorders, chronic pain and a variety of other problems traditionally the province of health psychologists and liaison psychiatrists. Behavioural experiments (as opposed to emphasis on verbal challenging of cognitions) whereby clients are actively encouraged to set up a situation which tests out the evidence for and against their beliefs, are growing in prominence (Bennett-Levy, Butler, Fennell, Hackmann, Mueller & Westbrook, 2004), and evidence for their specific effectiveness is now beginning to be gathered. Behavioural experiments are also being creatively used to help clients establish new, more helpful beliefs where these are not already available to them. This type of development reflects a growing realisation that the self and its organisation are much more complex than CT has often assumed, and may reflect the growth of interest in applying CT to more complex problems, and those with personality disorders. Manualised treatments have long been popular in RCTs, and self-help approaches, often based on these early manuals, are increasingly being published. A popular CT self help series is the Robinson “Overcoming” books. At present these focus primarily on Axis 1 disorders – where much of the RCTs have been conducted. New technologies – use of video feedback (e.g. in the treatment of social anxiety and eating disorders) and computerised treatment packages that can be self administered are in the process of being developed and evaluated (to treat, for example, depression in primary care settings), as well as in some cases to attempt to prevent disorders developing in high risk groups. Beating the Blues (Proudfoot, Goldberg, Mann, Everitt, Marks & Gray, 2003) is a popular computerised programme that is being tested in primary care, while several preventative eating disorder programmes are being developed (Austin, 2000).

Imagery
One example of a new approach in cognitive therapy, which has aroused a great deal of interest, is the application of imagery modification with clients with a variety of different types of distress (Hackmann, 1997). Many disorders are associated with spontaneous, recurrent images, which are seen as reflecting automatic thoughts, and which are a powerful way to access deeper levels of belief and meaning, which may have rich associations in many sensory modalities. These deeper level or core beliefs are invariably associated with specific early memories, and the beliefs associated with them are aften extremely painful and highly resistant to rational (or verbal) debate. Imagery modification aims, in such a situation, to help the client, using imaginal strategies, to change their sense of control over a key early memory, for example by increasing support for the person, changing the outcome of events, or modifying the implicit meaning contained in the memory/image.

For instance, a young woman with a long-standing body dysmorphic disorder reported a vivid memory of standing in the school play-ground when she was around ten years old, and in which she was asking a fellow pupil why he did not like her. The boy replied “it’s because you are ugly”. This had remained with her ever since, and manifested itself in repeated, recurrent images of herself as ugly, and seemed to be highly significant in driving her repeated and distressing attempts both to change her appearance, and a range of actions in which she attempted to hide her appearance from others (Osman, Cooper, Hackmann & Veale, in press). Working with early memories using imaginal techniques (as opposed to verbal challenging of beliefs)seems to be particularly helpful in changing the “felt sense” of being ugly, bad. worthless, no good, unlovable or whatever. The process by which this is done is still being developed, but is often based on procedures described by Layden, Newman, Freeman & Morse (1993) and Hackmann (1997).

To date, such techniques have not been rigorously evaluated in treatment studies. However, recent experimental work by Cooper and colleagues(Cooper, Todd & Turner, resubmission invited) demonstrates how an intervention based on modification of imagery may be used to augment cognitive approaches. In this study with eating disordered clients, the aim was to modify core beliefs about the self, and to give the client an enhanced sense of empowerment and control. Adult clients with an eating disorder were asked to think of an upsetting childhood memory that was clearly linked to their negative self beliefs, and the thoughts and feelings of the child were then explored. For the imagery group only, the image was then invoked as vividly as possible, and modified as the client wished. Normally this involved bringing in the image of a trusted, understanding adult, sometimes the adult self, to offer comfort or nurturance. Occasionally the outcome of events in the image was modified, for example by altering the ending so that someone who made hurtful comments retracted them or was punished. By contrast, the ‘treatment as usual’ group simply discussed negative self-beliefs and memories with the therapist, in order to explore the potential links between these and enhance their understanding of any connections. Cooper’s study showed that while negative beliefs about the self were changed by both procedures, and both groups significantly reduced their levels of eating restraint, a much more dramatic change was achieved in the imagery group, who showed a significantly greater reduction in negative “emotional” (or felt sense) self belief than those in the “normal” intervention. In addition participants in the imagery group reported after the intervention that they were now very much more likely to believe (“emotionally”) that they had deserved help and protection as a child. Importantly, decreases in negative self beliefs were also associated with self reported changes in mood and eating disorder related behaviour. This very preliminary study provides some initial experimental support for the clinical work that has been carried out by cognitive therapists in this area.

Theoretical Developments
Besides developing new techniques such as working with imagery to change core beliefs, CT theorists have also been exploring the underlying cognitive model in more depth. The metacognitive self regulatory executive function model (S-REF) (Wells, 2000) and the Interacting Cognitive Subsystems model (ICS) (Teasdale, 1997) have recently been developed, as have ideas from Dalgleish (also presented at the ACAT conference). Wells (2000) highlights the procedures that are involved in maintaining problems and distress, rather than the more typical CT tendency to emphasise the content of the relevant cognitions. Teasdale (1997) emphasises the implicational level of meaning, and the importance of changing the client’s relationship to their cognitions. Both theories provide an explanation of “emotional” belief or the sense that a belief is true, even though the client knows rationally that it is not – an aspect not traditionally addressed in CT, and both suggest specific intervention strategies that are designed to alter this. Wells has developed attention control training, while Teasdale has focussed on the development of mindfulness based CT. Interestingly, these approaches all (implicitly if not explicitly) acknowledge the relative poverty of existing cognitive theories in understanding the self, and CT’s relative neglect of developmental issues. Such models expand the explanatory power of the original Beckian schema model, include a greater emphasis on “self”, generate novel and more complex predictions than the initial model, and help to begin to explain the development of disorders and distress in addition to the maintenance of disorders and symptoms. Evidence relevant to their predictions is beginning to appear, and this experimental testing is a strength, which allows for the evolution of theories which have a sound empirical basis. On the other hand, while admirable in many ways, this approach potentially risks detachment from everyday clinical work, and its undertaking is also dependent on the vagaries of research funding, decisions about which are not always as evidence-based or unbiased as might sometimes be thought or claimed.

What are the Key Differences Between CAT and Cognitive Therapy?
A number of CAT papers (for example, Bell, 2002; Denman, 2002; Moorey, 2002; Marzillier and Butler, 1995; Sutton, 2002) have already addressed this question elsewhere, and we are indebted to these contributors for some of the points included below.

Perhaps the most obvious and important difference is the underlying model, which for CAT is dialogic and relational, which means placing the individual firmly within a relational and social context. By contrast the basic model of CT is individualistic, and as such is consistent with both everyday Western individual and medical models of the person. In CAT there can no more be a person without relationships than there can be a baby without a mother (c.f. Winnicott). CT therapists may not ask about family of origin issues, indeed this information is not necessarily considered relevant when developing a preliminary formulation of what is maintaining the problem, or indeed to commence treatment. More routinely, cognitive therapists will identify and address the individual’s faulty cognitions and beliefs in relative isolation from other factors, while CAT therapists will ask with what perceived, enacted or anticipated reciprocal relationship procedures are these cognitions and beliefs associated? The focus of CAT is on procedures and reciprocations, while for CT it is on symptoms and cognitions. CAT therapists focus on structure and sequences, and how these are related via relationships, while cognitive therapists are more likely to work with a symptom without much emphasis on the relational or historical context. Of particular importance, CAT has a more clearly articulated model than CT for addressing the self and self-states, and perhaps most helpfully of all, has a clear method for recognising the role of the therapist through reciprocation and enactment, and for discussing this through inclusion in the SDR. This permits a more holistic view of the client, as well as clearly addressing the role of the therapist in the relationship with the client.

How Can CAT Learn From Cognitive Therapy?
Any casual observer of the therapy scene in the western world will immediately notice the effectiveness of CT in dominating texts on evidence based practice, and in steering current therapeutic approaches in a multitude of practice settings towards CT. CT has been highly effective in carrying out carefully designed research studies and in disseminating its positive results. This has occurred despite the fact that research evidence on the outcome of psychotherapies clearly shows that a range of therapies besides CT are also effective and that despite technical diversity, “all have won and all shall have prizes” (Roth & Fonagy, 1996; Wampold, 2002; Lambert & Ogles, 2004). Yet CT appears to be winning the race for the evidence based therapy of choice in many settings, and for a variety of problems. CAT has published relatively few outcome studies and in the current world of evidence based practice, CAT will continue to have to deal with question marks about its effectiveness until, like CT, this has been achieved. Despite acknowledging some of the limitations of the methodology of the randomised controlled trial, and its questionable applicability to psychotherapy, CAT suffers from not being able to point to a substantial research record in the way that CT can . Even if many observers can document the weaknesses in such studies, their existence contributes significantly to the growth and influence of cognitive approaches. CAT clearly has to learn from this, even if it does not like the lesson.

Another important aspect of CT is its apparent willingness to address the symptom or problem in a direct and relatively uncomplicated way. Many services users tell us that they just want to feel better and that their primary concern is to obtain symptomatic relief. Not everyone wants to understand their procedures and reciprocations. There is very probably a place for CT in being able to do this. Certainly some symptoms do appear to be very ably and relatively quickly addressed by CT, including panic, phobias, generalised anxiety disorder (GAD), health anxiety, and many instances of PTSD, depression and obsessional compulsive disorder (OCD). For some of these forms of distress, CAT may require more work and thought from both therapist and client, and this may be rather more than the client necessarily wants or needs, or indeed than the service wishes to afford. The simplicity of the language and models used by cognitive approaches may also contribute to its widespread influence, and its popularity amongst service providers. It has also been quick to respond to the development of new technologies, and to adapt treatment delivery to fit in with NHS strategic and economic developments.

Lastly, the behavioural tradition that underpins CT has always been conscious of systemic and contextual issues, but in a very clear and straightforward way. CT can be criticised for paying little attention to the complexities of these issues but what it does do very effectively is point to the way in which behaviours are a function of reinforcement contingencies. This apparently simple insight into why people sometimes behave as they do remains powerful. It is central to behavioural approaches and has had a significant influence on the provision of services to many client groups. CAT would do well not to ignore this apparently straightforward observation, and make use of it in formulation and promotion of the therapy.

How Can CT Learn From CAT?
Undoubtedly there are many areas where CAT could enrich CT. Primarily, CAT’s dialogic, relational model allows for a far richer and sensitive appreciation of people in relationship than is possible with an individualistic cognitive model. The psychodynamic roots of CAT also provide access to an enormously varied tradition of understanding people and their development, which has in the past been mostly ignored by cognitive therapists, undoubtedly to their great loss. CT is only now considering the importance of the self and the person and its myriad manifestations. One difficulty it is having here is that there are no easily accessible ways of talking about the self and the person in CT as there are in CAT, and ideas and notions from CAT may be helpful to CT here. Another key advantage for CAT over CT is that it has both a method and language (tools) for addressing transference and counter-transference and enactments in non-blaming ways, and for helping therapists to understand their own behaviours and responses to clients. When working with abuse survivors, for instance, understanding the capacity of clients and therapists to behave as both abusers and survivors can be enormously enlightening and empowering (Llewelyn, 2003). CT is only in a very rudimentary stage of addressing and considering such issues. CT is increasingly being applied to more complex cases, including clients with multiple diagnoses, long standing, chronic difficulties and personality disorders; while CAT arguably has treatment strategies that are more compatible and applicable to such clients in whom issues of the self and the therapist-client relationship are typically more important than when a client has a relatively uncomplicated Axis 1 disorder.

Conclusion
This paper opened by asking what cognitive approaches may have to contribute to CAT. Along with many ACAT conference attendees in March 2004, this paper suggests that there is quite a lot, both in theory and in practice. Recent approaches, for example the elaboration of more sophisticated developmentally informed models, and the incorporation of imagery and non verbal strategies, strengthen the case for CT’s contribution. Yet there are clear distinctions and differences in theory and technique which distinguish CAT, and explain why CAT does see itself as unique, and why CAT should not be bracketed with CT simply as a similar or overlapping cognitive approach. This paper has outlined some of these reasons as well as pointing to some of the positive aspects of the cognitive tradition.

We conclude by raising a few thought about the future development of CAT in a therapy world dominated by the twin colossuses of psychodynamic therapy and CT. The recent history of both these approaches suggest that they are moving slowly towards each other. For example, CT therapists now talk about transference, while psychodynamic therapists are trying to develop briefer interventions. Arguably the problem of CAT will be holding onto its ground as an integrative therapy which incorporates many of the advantages of both. CT seems to be particularly adept at incorporating bright ideas, as has been shown in this paper by recent work on imagery, which would have been unthinkable in CT a decade or so ago. One real possibility for CAT is that many of its insights will be re-possessed and re-packaged by CT in the decades to come.

CAT and Cognitive Therapists share many key assumptions and practices, but there are important differences, and one in particular may constitute the real long-term contribution of CAT. This is CAT’s underlying dialogic and relational model. But therein also lies one of CAT’s difficulties: the world around us does not think in dialogic, relational terms but is instead predicated on the existence of an unique individual who is only in a marginal way socially constructed. Remember Margaret Thatcher’s remark: “There is no such thing as Society”. CAT’s ideas are counter-cultural, at least in Western society, and require careful exposition and explanation. Many have pointed to the growing trend of individualism in all aspects of our society – and some have linked this to the increase and cross cultural differences in prevalence of certain psychological disorders (e.g. Cooper, 2001). CAT therapists believe that an understanding of people in relational terms constitutes a better reflection of psychological reality than an individualistic approach. It is interesting, however, that CTs too are slowly coming round to the idea that relational aspects are important, and that the formulations for some clients must be more complex than initially thought and require attention to some of the constructs (particularly that of the self) that are key in CAT. Also growing in CT is the idea that treatment with such clients benefits from consideration of therapist-client issues. We remain hopeful that the relational emphasis of CAT will be one that will stand the test of time, and may well have a beneficial impact on the development of other therapeutic traditions, including CT.

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Sue Llewellyn
Myra Cooper

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