CBI – Extra Literatuur
Voorbereiding
Chapter 1 – The Core Principles of Cognitive Behavior Therapy (O’Donohue &
Fisher, 2012).
Chapter 2 – Clinical Functional Analysis: Understanding the Contingencies of
Reinforcement (O’Donohue & Fisher, 2012).
Chapter 1 – Basic Principles of Cognitive-Behavior Therapy (Wright, Basco, & Thase,
2006/2017).
Chapter 1 – The Core Principles of Cognitive Behavior Therapy
Cognitive behavior therapy (CBT) is an important therapeutic paradigm as it has been shown
repeatedly to be an efficacious and effective intervention for a wide variety of psychological
problems, while other therapeutic paradigms have not. In this sense, CBT may be said to be
the only or at least the foremost paradigm in psychotherapy. It is not a ‘one problem therapy’
as arguably some other interventions are, such as eye movement desensitization and
reprocessing (EMDR) for posttraumatic stress disorder (PTSD).
Advantages of CBT
CBT has several significant advantages;
It is often quicker compared to other therapies. CBT often involves a dozen or a few
dozen hourly sessions in individual therapy, which is still a significant time
commitment, but much shorter than most other forms of therapy.
Following from the time-efficiency, cognitive therapy can also be cheaper, as time is
the major driver of cost in most therapies.
Cognitive therapy is a manualized therapy, which thus can be scaled readily. This
means that it can easily be taught, and that it can’t be performed by just one or a few
therapists, but thousands can.
Disadvantage
The notion of manualized therapy however also comes with a significant problem.
Manualized therapy aims to fix the problem of fidelity, namely the different execution
of the same therapy by different therapists, in different settings, with different clients.
However, there are over 600 diagnoses in the DSM, and it cannot be expected of
therapists to master a manual for each and every single disorder.
The fidelity problem becomes even more complex, when comorbidity and any other
secondary variables are considered (such as therapist experience or intelligence).
Would there be a manual for an individual with major depressive episode that also is
suffering from comorbid panic disorder? Would there need to be still another manual
for an individual with these two problems who is also Hispanic? The number of
permutations clearly becomes unmanageable.
A treatment manual consists of different requirements and subgoals, some of which
are more important than the other. Clearly stating exposure principles are for example
more important than discussing homework in the second session. Therefor it’s
important that outside of the manual, therapists also have an understanding of the core
1
, principles of behavior therapy, to be able to effectively deliver evidence-based
treatments.
Treatment manual also do not take the idiosyncratic nature of actual clinical cases,
into consideration. Again, having an understanding of the core principles embodied in
the manual can be helpful to successfully adapt a manual to an idiosyncratic situation.
For example, watching your brother die from a untreated rattlesnake bite would be
unlikely to be featured in a treatment manual for PTSD, but with basic knowledge of
trauma processing, a therapist would be able to adapt the manual to this particular
case.
Understanding core principles
So, thinking in terms of core principles allows for a deeper understanding of the mechanisms
of change underlying treatment. This is very important, because it means that the 600+
diagnoses in the DSM do not all have to be treated differently, with their own treatment
manual, consisting of unique change principles underlying each diagnoses. Instead, it seems
like a set of core principles underlies effective cognitive behavior therapy. For example, most
anxiety disorders get treated through exposure therapy and modifying beliefs. And both skills
acquisition and contingency management seem to be the key underlying treatments for people
with autism spectrum disorders. Thus, understanding some central core principles can provide
a more coherent and parsimonious way of understanding the treatment of a broader range of
individual disorders. Besides, understanding core principles also leads to a better
understanding of change processes. Treatment manuals consist of a whole lot of details, but
not every detail is as important for therapeutic progression. Understanding the principles in
the therapy manual gives a better understanding of the key components of treatment, which
are needed for change. And understanding of the core principles underlying the manual can
help the clinician make effective modifications to better fit the needs of individual patients.
To allow for a better understanding of the underlying importance of some of the goals, the
therapy manuals should be explicit on what principles they are attempting to instantiate.
For example: In the next two sessions, two principles are being implemented;
1. Identifying and modifying irrational beliefs.
2. Apply behavioral activation principles so as to increase the patient’s contact with
positive events.
Therapy is not an art
The identification of key principles underlying effective behavior change, leads to the
conclusion that therapy is not necessarily an art, but more a technical enterprise. This is
because it involves the skillful application of the active ingredients of change, which is partly
a technology. It therefore is also not allowed to just implement any form of therapy.
Therapists cannot simply implement a therapy that has caught their fancy but rather must
design and implement therapies that are based on principles that have been supported as
effective. In for example rebirthing, psychoanalysis, or supportive psychotherapy there are no
identified causal mechanisms that can bring about change, especially compared to empirically
established treatments such as CBT. The case therefore could be made, that therapists need to
make choices, based on which therapy form is going to produce what changes. This implies
there are right answers in therapy, and that it again is not just a free-form art, but rather at
least partly a technicality. Thus, to some extent, therapeutic eclectism ought to be dead. It
2
, can only be justified by adding other empirically supportive techniques, like for example
when interpersonal techniques are added to CBT treatment for depression (since interpersonal
therapy has also been shown to be effective). The possibilities for such empirically supported
eclecticism however are very limited, because of the lack of evidence of the efficacy of the
techniques from other therapy theories.
The Varieties of Instantiations of These Principles
Truly understanding the core principles of effective therapy can also contribute to finding
different ways how they can be implemented. Recently there has for example been a growing
interest to instantiate core principles in delivery modalities that are less costly, quicker, and
more accessible. This is an important and promising development, that again points to the
importance of understanding these core principles. A good example is the development of e-
health, which has grown tremendously over the past couple of decades and which has the
potential to allow core principles to be delivered at low cost over the web to millions of
consumers. In an important sense, e-health is based on the commitment that it is the change
principle that is important to instantiate, not the non-specifics of the therapeutic relationship.
The Structure of CBT: Where Do Principles Fit In?
Behavior therapy is a complex approach to the treatment of human problems. It began with a
few simple principles in the 1950s, and over the years it expanded with extra techniques such
as contingency management (Skinner) and relaxation and exposure (Wolpe). Just like
behavior therapy, contemporary CBT is also not a one- or two-principle therapy. It is based on
a number of principles (in this book 13 major principles are discussed), from exposure to
positive psychology, which sometimes are interrelated. To be competent at CBT, one has to
understand and be able to implement these principles.
So, the intellectual groundings of CBT are also fairly complex. It can be said to have broad
philosophical aspects, often involving views of the philosophy of science. Going down from
abstract to concrete, the next step in CBT’s intellectual edifice might be the theories of CBT,
which provide a broad explanation. The next level is the empirical regularities, which often
ground CBT in basic experimental psychology. It is also important to recognize that it is
certainly not the case that all CBT emerges from these empirical regularities. Another part of
CBT’s intellectual edifice is the borrowing of principles from a variety of sources (such as in
stoic philosophy, like Albert Ellis did). The last two other levels are principles and
techniques. Techniques are the specific instantiations of principles, which describe how to
perform the principles such as systematic desensitization. There can be a variety of techniques
that can embody the same principle; graduated exposure, flooding, systematic desensitization,
imaginal exposure, and EMDR may all be specific techniques, which embody the same
principle of exposure. Each technique should be based on a principle. Principles are like
general rules that depict potent causal mechanisms that produce behavior change. They
consequently play a key role in the intellectual edifice of CBT.
So, to summarize the Major Components of the Intellectual Edifice of CBT;
Philosophy – For example, radical behaviorism.
Theories – For example, alarm theory or relational frame theory.
Experimental Regularities – For example, extinction, habituation, automatic
cognitive processing.
3
Voorbereiding
Chapter 1 – The Core Principles of Cognitive Behavior Therapy (O’Donohue &
Fisher, 2012).
Chapter 2 – Clinical Functional Analysis: Understanding the Contingencies of
Reinforcement (O’Donohue & Fisher, 2012).
Chapter 1 – Basic Principles of Cognitive-Behavior Therapy (Wright, Basco, & Thase,
2006/2017).
Chapter 1 – The Core Principles of Cognitive Behavior Therapy
Cognitive behavior therapy (CBT) is an important therapeutic paradigm as it has been shown
repeatedly to be an efficacious and effective intervention for a wide variety of psychological
problems, while other therapeutic paradigms have not. In this sense, CBT may be said to be
the only or at least the foremost paradigm in psychotherapy. It is not a ‘one problem therapy’
as arguably some other interventions are, such as eye movement desensitization and
reprocessing (EMDR) for posttraumatic stress disorder (PTSD).
Advantages of CBT
CBT has several significant advantages;
It is often quicker compared to other therapies. CBT often involves a dozen or a few
dozen hourly sessions in individual therapy, which is still a significant time
commitment, but much shorter than most other forms of therapy.
Following from the time-efficiency, cognitive therapy can also be cheaper, as time is
the major driver of cost in most therapies.
Cognitive therapy is a manualized therapy, which thus can be scaled readily. This
means that it can easily be taught, and that it can’t be performed by just one or a few
therapists, but thousands can.
Disadvantage
The notion of manualized therapy however also comes with a significant problem.
Manualized therapy aims to fix the problem of fidelity, namely the different execution
of the same therapy by different therapists, in different settings, with different clients.
However, there are over 600 diagnoses in the DSM, and it cannot be expected of
therapists to master a manual for each and every single disorder.
The fidelity problem becomes even more complex, when comorbidity and any other
secondary variables are considered (such as therapist experience or intelligence).
Would there be a manual for an individual with major depressive episode that also is
suffering from comorbid panic disorder? Would there need to be still another manual
for an individual with these two problems who is also Hispanic? The number of
permutations clearly becomes unmanageable.
A treatment manual consists of different requirements and subgoals, some of which
are more important than the other. Clearly stating exposure principles are for example
more important than discussing homework in the second session. Therefor it’s
important that outside of the manual, therapists also have an understanding of the core
1
, principles of behavior therapy, to be able to effectively deliver evidence-based
treatments.
Treatment manual also do not take the idiosyncratic nature of actual clinical cases,
into consideration. Again, having an understanding of the core principles embodied in
the manual can be helpful to successfully adapt a manual to an idiosyncratic situation.
For example, watching your brother die from a untreated rattlesnake bite would be
unlikely to be featured in a treatment manual for PTSD, but with basic knowledge of
trauma processing, a therapist would be able to adapt the manual to this particular
case.
Understanding core principles
So, thinking in terms of core principles allows for a deeper understanding of the mechanisms
of change underlying treatment. This is very important, because it means that the 600+
diagnoses in the DSM do not all have to be treated differently, with their own treatment
manual, consisting of unique change principles underlying each diagnoses. Instead, it seems
like a set of core principles underlies effective cognitive behavior therapy. For example, most
anxiety disorders get treated through exposure therapy and modifying beliefs. And both skills
acquisition and contingency management seem to be the key underlying treatments for people
with autism spectrum disorders. Thus, understanding some central core principles can provide
a more coherent and parsimonious way of understanding the treatment of a broader range of
individual disorders. Besides, understanding core principles also leads to a better
understanding of change processes. Treatment manuals consist of a whole lot of details, but
not every detail is as important for therapeutic progression. Understanding the principles in
the therapy manual gives a better understanding of the key components of treatment, which
are needed for change. And understanding of the core principles underlying the manual can
help the clinician make effective modifications to better fit the needs of individual patients.
To allow for a better understanding of the underlying importance of some of the goals, the
therapy manuals should be explicit on what principles they are attempting to instantiate.
For example: In the next two sessions, two principles are being implemented;
1. Identifying and modifying irrational beliefs.
2. Apply behavioral activation principles so as to increase the patient’s contact with
positive events.
Therapy is not an art
The identification of key principles underlying effective behavior change, leads to the
conclusion that therapy is not necessarily an art, but more a technical enterprise. This is
because it involves the skillful application of the active ingredients of change, which is partly
a technology. It therefore is also not allowed to just implement any form of therapy.
Therapists cannot simply implement a therapy that has caught their fancy but rather must
design and implement therapies that are based on principles that have been supported as
effective. In for example rebirthing, psychoanalysis, or supportive psychotherapy there are no
identified causal mechanisms that can bring about change, especially compared to empirically
established treatments such as CBT. The case therefore could be made, that therapists need to
make choices, based on which therapy form is going to produce what changes. This implies
there are right answers in therapy, and that it again is not just a free-form art, but rather at
least partly a technicality. Thus, to some extent, therapeutic eclectism ought to be dead. It
2
, can only be justified by adding other empirically supportive techniques, like for example
when interpersonal techniques are added to CBT treatment for depression (since interpersonal
therapy has also been shown to be effective). The possibilities for such empirically supported
eclecticism however are very limited, because of the lack of evidence of the efficacy of the
techniques from other therapy theories.
The Varieties of Instantiations of These Principles
Truly understanding the core principles of effective therapy can also contribute to finding
different ways how they can be implemented. Recently there has for example been a growing
interest to instantiate core principles in delivery modalities that are less costly, quicker, and
more accessible. This is an important and promising development, that again points to the
importance of understanding these core principles. A good example is the development of e-
health, which has grown tremendously over the past couple of decades and which has the
potential to allow core principles to be delivered at low cost over the web to millions of
consumers. In an important sense, e-health is based on the commitment that it is the change
principle that is important to instantiate, not the non-specifics of the therapeutic relationship.
The Structure of CBT: Where Do Principles Fit In?
Behavior therapy is a complex approach to the treatment of human problems. It began with a
few simple principles in the 1950s, and over the years it expanded with extra techniques such
as contingency management (Skinner) and relaxation and exposure (Wolpe). Just like
behavior therapy, contemporary CBT is also not a one- or two-principle therapy. It is based on
a number of principles (in this book 13 major principles are discussed), from exposure to
positive psychology, which sometimes are interrelated. To be competent at CBT, one has to
understand and be able to implement these principles.
So, the intellectual groundings of CBT are also fairly complex. It can be said to have broad
philosophical aspects, often involving views of the philosophy of science. Going down from
abstract to concrete, the next step in CBT’s intellectual edifice might be the theories of CBT,
which provide a broad explanation. The next level is the empirical regularities, which often
ground CBT in basic experimental psychology. It is also important to recognize that it is
certainly not the case that all CBT emerges from these empirical regularities. Another part of
CBT’s intellectual edifice is the borrowing of principles from a variety of sources (such as in
stoic philosophy, like Albert Ellis did). The last two other levels are principles and
techniques. Techniques are the specific instantiations of principles, which describe how to
perform the principles such as systematic desensitization. There can be a variety of techniques
that can embody the same principle; graduated exposure, flooding, systematic desensitization,
imaginal exposure, and EMDR may all be specific techniques, which embody the same
principle of exposure. Each technique should be based on a principle. Principles are like
general rules that depict potent causal mechanisms that produce behavior change. They
consequently play a key role in the intellectual edifice of CBT.
So, to summarize the Major Components of the Intellectual Edifice of CBT;
Philosophy – For example, radical behaviorism.
Theories – For example, alarm theory or relational frame theory.
Experimental Regularities – For example, extinction, habituation, automatic
cognitive processing.
3
