3.5.7 Cognitive-Behavioural Modality

I certainly hadn’t much knowledge of the different modalities of helping people when I started street work in Southill in Limerick City in 1990!

I had completed a basic counselling skills course at that time – and on that course I was exposed to a different method of learning that is, experiential learning that I had not heard of up to then. I found this kind of learning very liberating and exciting. The element of it that I found hardest to accept (though also very exciting) was the idea of self-assessment, which I will discuss later. (Because of the script of my childhood, I always thought that assessing oneself would be at bit like praising oneself – that it wasn’t real assessment or real praise – it had to involve fooling oneself)!

I am mentioning this because I think that self-assessment has more of an emotional than a cognitive dimension to it – and this Sub-Chapter (as the name suggests) mainly concerns our cognition.

Getting back to our modalities, having been educated within the formal education system, the basic principles of Cognitive Behavioural Therapy, or CBT as it is generally known, (though I didn’t know its name), were actually quite familiar to me – as they are to most people.

CBT is one of two modalities that I believe are helpful to families in our Focus Group. And there is ample information on the nuts and bolts of CBT (and others that I mention) available from a wide variety of sources.

In the website my basic descriptions of the modalities will be very brief but I will focus on their usefulness in respect of our aim to include families affected by imprisonment in some depth.

The origins of Cognitive Behavioural Therapy (CBT) are rooted in behaviourism, which tends to view human behaviour as reactive.

In other words, humans react to external stimuli to satisfy needs and wants.

Behaviourism proposes that we are conditioned to behave in certain ways by either continual reward or continual punishment of certain actions that we engage in.  It assumes that the brain is a blank canvass at birth which makes it easy to influence. 

This conditioning was manifest in many experiments involving animals, e.g. monkeys, dogs, rats, probably the most famous being the Pavlov’s Dog experiment where a dog salivated on hearing a bell it associated with food.

It was further developed by the psychologist B. F. Skinner and others who gave it a fancy name; Operant Conditioning in the early decades of the 20th Century and thereafter became very popular in the world of psychology.

Behaviourism, or operant conditioning, is, of course, a very seductive model in terms of getting people to conform to society’s norms and expectations.

It is true that we are conditioned to behave in certain ways by experiencing punishment and/or reward.

It seems to make sense, and fits in with our general experience of the world.

Looking back now, it can be said that behaviourism was a phase in the evolution of methods of helping people in distress and was a stepping stone on the road to CBT [1]

[1]. Here is a brief history of CBT if you are interested.

Cognitive Behavioural Therapy differs to Behaviourism (which many practitioners who cared about people in distress found to be lacking in warmth and humanity) in that it acknowledges the potential of the human being to cognitively (i.e. by thinking) change their own world, their environment, their emotions and then their behaviour so that they will be happier and more content.

(We’re getting close to emergence here)!

As the name suggests, it focuses on the cognitive (thinking) abilities which we all have, and the usefulness of these abilities in our life’s project.

The CBT therapist will encourage the person who is suffering, first to identify and then practice strategies that are linked to goals that are achievable.  The good enough practitioner will have enough experience, common-sense, and empathy to assess what level the person in distress is at so that she won’t set the bar too high and cause the person to be disappointed by failure to achieve the goal. 

However, as the goals are achieved, they are increased in difficulty and with more success the symptoms of the disorder gradually get less intense, less frequent, and less distressing for the person seeking help.

(This, of course, mirrors our mainstream education system where we start with very simple literacy and numeracy tasks in Baby Infant class and gradually the tasks increase in difficulty until we reach Leaving Certificate – which is why I said in a previous post that the principles of CBT were very familiar to me even though I didn’t know what it was called).

CBT uses reward (that is, achieving goals are rewarded by reduction in distress) far more than punishment, and indeed the principles of cause and effect are clearly evident. The cause is the hard work of the individual, affirmed all the way by the therapist or practitioner, and the effect is, of course, the reduction in distress.

Our brain does an incredible amount of information processing every second of every minute of every day – and CBT uses this power to change distorted thinking and harmful behaviour by continually practicing new coping mechanisms.

Positive feedback – that is, dwelling on, and affirming things that have worked well, and then repeating them – is a very powerful aspect of CBT, because, as we all know, success usually breeds success.

CBT has been found to be very effective in many areas, e.g. depression and anxiety, post-traumatic stress disorder, obsessive compulsive disorder, phobias, and some forms of addiction – if they are not acute.

Because adolescents’ brains are growing and developing, CBT can be very helpful in moderating aggression and addressing challenging behaviour in teens.  Psychiatrists who are treating depression and anxiety will often recommend CBT in combination with prescribed medication.  And as far as I am aware, CBT is one of the few non-medical-model disciplines in which psychiatrists are required to be trained.

Motivational Interviewing, Solution Focused Brief Therapy, Narrative Therapy and similar methods of supporting people are all off-shoots of CBT – and all work well in solving problems like those described above and easing people’s distress.

And CBT does seem to make sense! After all, if we are rewarded, we do more of something.

If we then cognitively acknowledge this using the mighty power of our brain, and proactively apply it in our life we can change our world for the better.  This is what, within normal development trajectory, happens at 2 or 3 years of age, when a child has a tantrum to get something he wants but slowly learns that instant gratification is not possible in the real world. (It is necessary to remember here that this happens within the context of good enough, loving, secure family relationships).

The principles of CBT are actually the basis of most formal mainstream education, employment, promotion, overall success in life etc.

In addition to relief of distress it can be used very successfully in training people to perform well under pressure, in sports, developing good living habits, dieting, healthy eating etc.

As I said in a previous post I began my journey in the world of helping people by doing streetwork.

It didn’t take me too long to realise that reward and punishment, and cause and effect which work so well in the world at large (and work very well for me) would not work with young offenders on the road to full blown addiction, and on the fringes of homelessness and inevitable imprisonment.

There were some young people who seemed to respond well to cause and effect type reasoning – but there were some who did not respond at all.  There were young people who would respond in a one-to-one situation but not in a group of their peers.  And there were young people who no matter what the circumstances were, when they were having a tantrum, no reasoning would work.

However, after some time, and many different experiences and observations, I came to believe an appropriate emotional response was better than all the reasoning in the world.  This is because emotional responses worked with everyone – cognitive reasoning only worked with some.

(This is revealed in Example 1 and Example 2, – positing the usefulness of creativity, compassion and surprise where CBT would not have worked at all).

I also guessed that many would have experienced emotional responses that were unhelpful, i.e. anger of someone who could and would hurt them, or, perhaps, anger of a practitioner who would exclude them. 

But a good enough emotional response would not have to be based on anger or fear – it could be love, sadness, joy or simply acceptance – and this, I believe, is why the element of surprise worked in the two examples.

And sometimes reason worked better with certain young men who were looked up to and then they would tell others to cop themselves on.  (These were valuable experiences because we were identifying those with leadership potential).

The ones who needed the emotional response most were the many young people, mostly male, who appeared to have nothing to lose in respect of reward and punishment.

They had no prospect of employment, no opportunity for education, (having been thrown out of school), no prospects of being included in sports clubs no matter how talented they were (and some were very talented), no sense of pride or respect for themselves, and/or their families or communities, no apparent fear [1] of disapproval of adults, of Gardaí, of being on probation or even, it appeared to me at any rate, going to prison. (That is where this song came from).

Something like going to prison that I – and anyone that I had known up to that point in my life – would have absolutely dreaded appeared to hold no fear for these young people on the street [2].

At this point I need to remark that our beliefs about reward and punishment are not always as simple as they seem on the surface.

For anyone wondering why a child chooses to engage in anti-social behaviour there is one major and very obvious conundrum.  If the greatest gift that we can give a child is positive attention, (reward), why would a child continually do something that attracts negative attention (punishment)?

And if the ultimate punishment is prison, why do people engage in behaviour that will lead them to going there.  (This was dealt with at some length in the Chapter on Trauma and Related Topics, specifically in 3.4.6 and 3.4.8 so if you have jumped to this post a read of those might be helpful).

The classical behaviourists explain such a paradox by proposing that the parents (or teachers) are not really schooled in how to reward and punish appropriately. The next post will offer a different view.

[1]. I use the word apparent deliberately.  I believe that such young men and women are actually consumed with fear – but it is not obvious at first glance to their peers or casual observers

[2]. Having observed this apparent fearlessness over many months, and being quite amazed at it, I had one rather funny experience.  One night doing streetwork, around a bonfire with cider-drinking young men, the one that we all considered the toughest of all, aged about 17, got all excited and agitated.  He hurriedly asked his friends to gather around him and hide him. I then observed the cause of his high anxiety – his mother passed a short distance away from us walking home along a path.  Yes, he was still afraid of his mother!  

Even the most enthusiastic CBT practitioner will acknowledge that it has, on its own, certain limitations in treating trauma, and, in particular, trauma within the imprisonment experience.

Of course, the technique of CBT doesn’t have to be time-limited – it can be practiced over a long time in diverse environments and sometimes is. But in my experience CBT practice is (generally) biased towards change happening, and when it doesn’t happen quickly enough it is generally the individual who is thought to have the problem, not the modality or the practitioner.

One reason why it struggles to reach people who are carrying trauma is that it is often delivered in time-limited segments, sometimes called courses.  These can, of course, be one-to-one, for example ten weekly therapy sessions or in a group setting.  Many of the ones that I am familiar with are or have been designed in academia and sold under franchise to agencies responsible for supporting vulnerable people in communities.

Personally, I have never experienced a time limited CBT programme to be attractive to the people who need the most assistance – those in the most acute distress, who are very isolated, who are in continual crisis, and/or who have suffered severe trauma. 

They are wonderful for people who have the emotional stability to absorb the cognitive aspects of the programme – and many such people thrive in such programmes.  And while not all CBT practice is time limited – as I stated above – much of it is, mirroring mainstream educational, linear, step-by-step learning.

Also, (as might be evident to you at this stage) systems theory challenges the primacy of the reductive or behaviourist methods of exploring the behaviour of living things – and in particular humans.  The reason for this is the presence of emergence which I already described.

We do not only react to stimuli and reward, we are not only conditioned to behave in a certain way by constant exposure to particular experiences, we also have our innate potential to grow in whatever direction, and at whatever pace we choose.

With the very hurt person, the primary work that needs to be done is the connection through which the trusting relationship is built, which will, in turn, enable something substantial to be laid down, on which the root foundations will work to heal the hurt.

And remembering the importance of connection, I came to the conclusion that reward and punishment would only work following the establishment of a trusting relationship, where care and nurture was of paramount importance, the primary reward being the relationship itself, the secondary reward (or carrot) being the approval of the adult with whom the young person had the relationship, and, perhaps, the punishment (or stick) being the disapproval, or the withdrawal of that care and nurture.

Not only that; the sincerity, commitment but above all consistency of the relationship would constantly be tested by the young people showing us their most obnoxious selves – almost hell bent on proving, both to themselves and us, that it was impossible for them, or they didn’t deserve, to be in relationship.

When all that work is done – there is a good chance that there will be a place for CBT.

This brings me to the next Sub-Chapter in our Modalities Chapter – Person Centred Therapy.