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Chapter 6. Cognitive-Behavioral Practice
Cognitive-behavioral theories (CBT) provide social work practitioners with a tool focused on developing
rational management of an individual’s behavior and so better understand the source of their problems.
CBT attempt to have the individual manage and change their behavior so as to resolve social problems that
affect them. CBT—now seen as a single area of practice—was derived by the integration of behaviorism,
supported by learning and social learning theory, and cognitive theory.
Terminology
Behavior therapies focus on changing specific behaviors.
Cognitive therapies focus on changing inappropriate thinking processes.
Cognitive-behavioral therapies focus on how thinking processes generate behavior patterns.
Social learning focuses on the learning that results from people’s perceptions of social experiences.
Assertiveness training enables people to practice behaviors so that they can gain confidence in their
behaviors thus improving their overall social confidence.
Reinforcement of useful behaviors is used.
Modeling is a form of social learning in which people understand and copy useful behaviors from a valued
role model.
Motivational interviewing may be used to engage challenged clients.
Mindfulness techniques focus on paying attention to important issues in our lives.
Key Ideas
Cognitive and behavioral ideas come from four main streams of psychological writing.
These four are learning theory leading to behavior therapy; a number of cognitive therapies including
reality and rational emotive behavior therapy; social learning theory and social skills training; and
mindfulness thinking.
Behavioral practice has made many positive contributions.
Behavioral practice focuses on specific behaviors that worry clients and other around them—if we change
the behavior, we remove the concern. Practitioners made a clear analysis and description of problems
based on direct observation. Methods of assessment, intervention and evaluation are explicitly defined.
Factors influencing behavior are identified by changing some factors in the situation and looking for the
changes that result. Progress is monitored using subjective and objective measures, comparing data about
the present with data about the situation before the intervention took place. Practitioners help clients to
use changed behaviors in many situations and maintain improvements after the intervention has ceased.
Behavioral work seeks to help people respond appropriately to social events.
The main aims of behavioral social work are to increase the desired behaviors and reduce the undesired
ones, so that people respond appropriately to social events. CBT theorists argue that this increases
people’s capacity for leading a full and happy life. An insight into people’s problems often helps because it
speeds learning, but there is no evidence that it is necessary or that it is enough to get people to change.
CBT writers claim that warm, trusting personal relationships between workers and clients help in
behavioral work, as they do in other forms of social work.
Behavioral social work can be used in many social work situations.
These include practice such as direct work with children and child protecting, people with severe earning
disabilities, offenders, carers, individuals with addictions, people with mental health problems, and those
in residential and group care for elders as well as generally in clinical psychology and some specialized
forms of counseling.
Theories of CBT are primarily a Western model of practice.
These theories emphasize the psychological change of individuals, rather than the broader social grouping
that might be more relevant in developing countries as well as using a Western model of the scientific
method that is less influential in many Eastern countries.
CBT has a limited use in specialized settings with client groups.
For example, it is often used for school phobia, childhood problems, and in psychiatric settings and with
mild anxiety and depression. CBT is also used in criminal justice settings in particular because patients
can receive adequate supervision, and a patient-centered and sympathetic environment far more easily
than in a public agency.
One reason for limited use is the technical character.
A major difficulty with CBT is its technical character with much jargon and many formal procedures
requiring a detailed manual of procedures for practitioners. ‘Manualization’ can provide an ordered,
explicit approach to problems that can be clearly explained and justified but it may seem dehumanizing
and inflexible. Highly trained and capable practitioners may apply these manuals flexibly but less
experienced ones may be pressed by their agency to strictly follow the manual.
Values are a major concern for many practitioners.
CBT is used to manipulate behavior and client consent may be lacking thus leading to imposition of social
expectations on unwilling clients or pursuing authoritarian social or political policies. Behavioral models
have sometimes been misused such as in residential care homes. Defenders argue that client’s consent
should be obtained and that all techniques can be misused in the wrong hands. However, it is the
particular methods proposed by this theory that lead to the potential for misuse. As a result, some argue
that the ethically appropriate approach is to use the technique only where the client’s own purpose is to
free themselves from a particular behavior.
Several important ideas underlie behavioral therapy.
There are several important ideas underlying behavior therapy including respondent or classical
conditioning; operant or instrumental conditioning; learned helplessness; social learning and modeling;
and cognitive factors such as disorders of perception and attribution and catastrophic thinking.
Respondent conditioning is concerned with behavior that responds to a stimulus. Conditioning is a
process by which behavior is learned—and so we have learned to modify our behavior. Many behaviors are
unconditioned as they happen naturally. Behaviors are conditioned when responses become associated
with a stimulus that does not produce that response. Conditioned responses became generalized, that is,
the person applies them to similar situations. Extinction occurs if the association between the conditioned
response and the stimulus is not kept up. Counterconditioning seeks to associate desirable responses with
particular stimuli so that they act in competition with the undesirable responses. The most commonly
used counterconditioning technique is systematic desensitization.
Operant conditioning was the original form of behavioral practice.
This changed the contingencies that affected behaviors. An antecedent event produces a behavior, which
ties to deal with the event and because of that behavior consequences arise. Social worker manages
contingencies, which affect the relationship between behavior and consequences by reinforcement and
punishment. Extinction removes the relationship between behavior and its consequence.
The main process in social learning is modeling.
A persons sees someone else performing and action and pays attention to it. In turn, the observer forms an
idea of how the behavior is done. The observer identifies circumstances in which the behavior occurs.
When an appropriate situation arises the observer repeats the behavior.
There are a variety of therapies and techniques in cognitive-behavioral therapies.
Coping skills contain two elements a self-verbalization approach. Another therapy is cognitive
restructuring. This is perhaps best-known form of cognitive therapy and includes Beck’s cognitive therapy
and Ellis’s rational emotive behavior therapy. Structural cognitive therapy has core beliefs about
ourselves; intermediate beliefs are explicit descriptions people make of the world; and peripheral beliefs
are the plans of action and problem-solving strategies that we use daily. Workers focus on beliefs at the
periphery that cause problems but use the process of change to explore the origins of these beliefs in
deeper ideas.
CBT is widely used in criminal justice settings.
This is a good example of the practical use of CBT in agencies. These often include programs such as
aggression replacement training; strategies for self-improvement and change; moral reconation therapy;
relapse prevention therapy; and skills and education programs. CBT is used in a prescriptive manner
following a detailed manual and an explicit teaching program. As a result, offenders were intended to
move offenders away from stereotyped thinking about their own needs and allow them to see things more
broadly and from different perspectives thus leading to rational analysis and alternative approaches.
These practices often fit well with an increased emphasis on interventions focused on offenses.
Motivational interviewing can be used to motivate behavior change.
The main use of motivational interviewing is to engage clients who are not motivated to change their
behavior. This approaches uses empathy; develops discrepancy between the client’s values and behaviors;
deals with resistance; and supports self-efficacy. The main focus of motivational interviewing is to identify
and harness motivations for progress or change that may be hidden in a destructive lifestyle. Practitioners
try and help clients move through pre-contemplation; contemplation; preparing to change; taking action;
and then working on maintaining the change.
Mindfulness is a new approach from Buddhist thought and ideas in CBT.
Mindfulness emphasizes paying attention to the people you are interacting with and being receptive to
their communication. These concepts have connections with everyday ideas, research on interviewing and
communications and ideas about reflective practice. These ideas also connect with shared value principles
of alliance and rights. There are four forms of mindfulness-based psychotherapy: mindfulness-based
stress reduction, mindfulness-based cognitive therapy, dialectical behavior therapy, and acceptance and
commitment therapy.
Neuroscience is contributing to CBT and social work.
For example, neurobiology in social work is contributing ideas of plasticity; the differences between the
right and left hemispheres of the brain; information processing and memory; and the impact of physical
and psychological trauma on brain development. Much of current neurosciences research explores
functioning areas of the brain itself and how chemicals improve or inhibit neurological connections
between the body and the brain. Neuroscience offers a better understanding of the physical factors that
affect psychological reactions and social relations, although it does not say that physical factors override
the psychological and social. This is particularly useful in areas of practice such as attachment and
bonding, trauma, psychotherapy, and medication and drug abuse.
Issues
CBT lies at the center of the ongoing controversy about EBP.
Adherents claims CBT has the best and longest developed evidence base for its effectiveness. However, the
most important critiques of CBT are regarding the limitations of that claim. The arguments center on
whether CBT’s focus on defining and modifying specific problems in the client’s behavior is successful only
with a range of mental health problems. CBT may have a degree of effectiveness with those types of
problems but that may come at the cost of focusing on and perhaps amplifying problems rather than
looking positively at strengths and objectives as well as strengths as proposed by solution-focused
practice. Due to the focus on problems, CBT thus seem to be contrary to the shared value principle of
seeking positive objectives although it does have a strong focus on outcomes.
CBT is not relevant to the broad range of social work services delivered to clients.
CBT is well reviewed regarding a range of mental health disorders, primarily forms of anxiety, phobias,
depression, and post-traumatic stress disorders.
CBT’s arguments are oriented to positivism, modernism, and linear explanations.
Accepting the arguments for CBT requires acceptance of the relevance of positivist research methods in
social work, modernist ideas about knowledge (there is universal knowledge relevant in every culture), and
linear models of explanation (simple cause and effect). The disputes between CBT and opposing writers
appear to many people to be an example of sterile conflict over theoretical ideas that contribute little to
help practitioners.
Positivist arguments for CBT do aid in working with some other professions.
For example, medicine and psychology knowledge bases emphasize positivist research techniques and
thus look upon social work use of CBT in a favorable light. The opposing argument is that CBT may be
chosen in some degree to seem ‘professional’ to different profession. In defense of CBT, there are
techniques, which are possible for experienced practitioners from several professions to use without using
CBT fully, and thus borrowing techniques in clearly defined situations can be helpful in some cases.
Other criticisms of CBT come from critical and feminist theory.
Critical and feminist theory criticize CBT for seeing all problems as coming from an individual’s mind and
ignoring the impact of social oppression. These critics claim that CBT is unsympathetic to the needs of
women as clients and practitioners due to the positivistic research techniques. These critics see oppressive
social structures, powerful men, and a paternalistic social structure as an important source of both the
problem and the social perception that this is a problem that requires individuals to change. The feminist
critique goes further to question CBT’s way of thinking and researching and thus to reject the evidence
base of CBT because they also reject that the problem behavior of individuals ought to be the main focus of
social work interventions. As a result, critical and feminist claims that CBT change would be ineffective in
the long term if it does not tackle the social structures of oppression.
Final thoughts…
The main uses of CBT are in mental health settings, and in particular with depression and anxiety or
where a pattern of behavior due to life experiences requires behavior change of a learned psychological
disorder. Such situations are commonly found where someone is avoiding something that they recognize
that they need to do. Social learning can help people deal with things they find difficult, even with those
with learning disabilities seeking to improve there interpersonal and practical skills. Very structured forms
of CBT have even been used with challenging clients such as additions and criminal justice. The use of CBT
has come with some controversy regarding values and the use of EBP research justification; as a result,
CBT has been limited in general social work use in many settings and in many countries. In addition, CBT
approaches such as behavioral theory are highly structured and require precise identification of target
behaviors and a change program limited to that behavior. Such approaches are relevant in specialized
mental health services but impractical or even inappropriate in the average social work agency.