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Using Theories in Social WorkUsing Theories in Social Work

Cognitive-Behavioural ApproachesCognitive-Behavioural Approaches

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In order to comprehend these approaches – In order to comprehend these approaches – what do we need to know?:what do we need to know?:

Some necessary background– psychological concepts – about how Some necessary background– psychological concepts – about how learning – particularly learning – particularly social learning social learning takes place. First background takes place. First background to behavioural, and then second CBT approachesto behavioural, and then second CBT approaches

Problems with simple behaviourist approaches Problems with simple behaviourist approaches Explanation of what CBT isExplanation of what CBT is Some distinctions between different types of understandings of CBT Some distinctions between different types of understandings of CBT

Some indication of where and with whom these approaches work Some indication of where and with whom these approaches work

well – not always traditional social work settingswell – not always traditional social work settings Strengths and weaknesses of CBTStrengths and weaknesses of CBT Some concluding, summative thoughtsSome concluding, summative thoughts

Also will help if we use some interesting Also will help if we use some interesting case studiescase studies – I will do this at – I will do this at appropriate juncturesappropriate junctures

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a) a) Background to Behaviourism: Some Background to Behaviourism: Some Psychological Concepts about Social LearningPsychological Concepts about Social Learning

Three main theories of social learning:Three main theories of social learning:

Respondent or classical conditioningRespondent or classical conditioning

Operant, or instrumental, conditioningOperant, or instrumental, conditioning

Social Learning Theory and modelling – more Social Learning Theory and modelling – more important for CBT – as it involves focus on important for CBT – as it involves focus on cognitioncognition

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11 Respondent ConditioningRespondent Conditioning

Presentation Presentation of foodof food

(Unconditioned response)(Unconditioned response)

SalivationSalivationRinging of bellRinging of bell

(Conditioned response(Conditioned response))

Higher orderHigher orderSwitching on conditioningSwitching on conditioningon of lighton of light

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Classical ExtinctionClassical Extinction

Conditioned ConditionedConditioned Conditioned Stimulus ResponseStimulus Response

Conditioned stimulus gradually disappearsConditioned stimulus gradually disappearswhen the unconditioned stimulus when the unconditioned stimulus

is removedis removed

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Example – Angry DriverExample – Angry Driver

Dangerous DrivingDangerous Driving

incident Anger/Aggressionincident Anger/Aggression

(original stimulus) (original stimulus) (original stimulus) (original stimulus)

Paired/associated (conditioned response)Paired/associated (conditioned response)

withwith

DrivingDriving

(conditioned response)(conditioned response)

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2 Operant, or Instrumental, Conditioning2 Operant, or Instrumental, Conditioning

Anne cannot control her 7 year old, daughter Jasmine’s Anne cannot control her 7 year old, daughter Jasmine’s behaviour without resorting to physical slapsbehaviour without resorting to physical slaps

She has been referred to youShe has been referred to you

Anne describes how Jasmine when shopping will scream and Anne describes how Jasmine when shopping will scream and shout until she gets what she wants.shout until she gets what she wants.

She takes Jasmine out of the shops…buys her sweets…She takes Jasmine out of the shops…buys her sweets…doesn’t work…..hits her legs…doesn’t workdoesn’t work…..hits her legs…doesn’t work

Now resorted to buying sweets as a bribe before going outNow resorted to buying sweets as a bribe before going out

Why do you think Jasmine’s behaviour is continuing?Why do you think Jasmine’s behaviour is continuing?

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For Jasmine clearly:For Jasmine clearly:

Sweets are very desirable….and so the Sweets are very desirable….and so the strong desire for them overrides any strong desire for them overrides any punishment so far offeredpunishment so far offered

Rewards strong; punishment weakRewards strong; punishment weak Jasmine KNOWS she will always get what Jasmine KNOWS she will always get what

she wants in the end…….she wants in the end…….

………………let’s diagrammatise an operant let’s diagrammatise an operant understanding of what is happening hereunderstanding of what is happening here

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Operant conditioning – we don’t just learn through association with Operant conditioning – we don’t just learn through association with

stimulistimuli……rather we learn behaviours as a result of the stimuli that rather we learn behaviours as a result of the stimuli that

immediately follows their expressionimmediately follows their expression

In other words In other words we learn as a result of the consequences we learn as a result of the consequences of actions rather than the stimulus that precedes of actions rather than the stimulus that precedes

themthemOperant conditioningOperant conditioning

Expression Expression of behaviour Stimulusof behaviour Stimulus(response) (consequence)(response) (consequence) Crying DemandingCrying Demanding Environmental Cue Environmental Cue (antecedent stimulus) (antecedent stimulus) Shopping Shopping

Other example of James and fatherOther example of James and father

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The different uses and aims of behaviour The different uses and aims of behaviour therapy – note focus on behaviour alonetherapy – note focus on behaviour alone Tackling generalised conditioned responses – going Tackling generalised conditioned responses – going

out/get dirty; school phobias; etcout/get dirty; school phobias; etc Aim would be Aim would be extinction extinction of generalised response of generalised response – – taking taking

child to school/park in stages – I used it with various child to school/park in stages – I used it with various phobias – spider phobiaphobias – spider phobia

Some kinds of behaviour are incompatible with others – Some kinds of behaviour are incompatible with others – counter conditioning counter conditioning – associating desirable responses – associating desirable responses with particular stimuliwith particular stimuli

Systematic desensitisation Systematic desensitisation common technique – common technique – relaxation/personal support – e.g. transvestites/ relaxation/personal support – e.g. transvestites/ agoraphobia/sexual therapy – reducing anxiety and agoraphobia/sexual therapy – reducing anxiety and therefore premature ejaculation; enuretic childrentherefore premature ejaculation; enuretic children

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Ethics/politics of behavioural therapyEthics/politics of behavioural therapy

In the 1960s there was a fearful debate about Skinner’s work – the In the 1960s there was a fearful debate about Skinner’s work – the behaviourist – notably in response to his book ‘Beyond Freedom & behaviourist – notably in response to his book ‘Beyond Freedom &

Dignity’Dignity’

Principally critics were concerned about:Principally critics were concerned about:

The absence of concern for ‘the mind’ – the ghost in the machineThe absence of concern for ‘the mind’ – the ghost in the machine The potential power that conditioning gave to the therapist to shape The potential power that conditioning gave to the therapist to shape

behaviour, and most importantlybehaviour, and most importantly The potential power afforded to corporate and political power holders The potential power afforded to corporate and political power holders

to condition their workforces/populations – cf Orwell’s to condition their workforces/populations – cf Orwell’s 19841984 and and Huxley’s Huxley’s Brave New WorldBrave New World

Have any of you seen Stanley Kubrick’s Have any of you seen Stanley Kubrick’s Clockwork OrangeClockwork Orange or read the or read the novel of the same name by Anthony Burgess?novel of the same name by Anthony Burgess?

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Technical efficiency cannot override moral Technical efficiency cannot override moral responsibilityresponsibility

Certainly pure behavioural techniques can appear ‘non-Certainly pure behavioural techniques can appear ‘non-human’ or inhumanehuman’ or inhumane

There is a real problem as we are aware that some of There is a real problem as we are aware that some of our fears have been realised in some residential token our fears have been realised in some residential token economy, behavioural modification settings such the economy, behavioural modification settings such the Pindown scandalPindown scandal

They can smack of the imposition of values – cf They can smack of the imposition of values – cf manipulationmanipulation

Behavioural therapists argue that consent is always vital Behavioural therapists argue that consent is always vital – and all therapy involves similar issues of limiting user – and all therapy involves similar issues of limiting user choice – but what when consent is related to gaining choice – but what when consent is related to gaining privileges?privileges?

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Background to CBT : Social Learning Theory and Background to CBT : Social Learning Theory and ModellingModelling

Background to these approaches can be found in the work Background to these approaches can be found in the work principally, but not exclusively, in work of Bandura (1977)principally, but not exclusively, in work of Bandura (1977)

People’s learning is achieved through their People’s learning is achieved through their perceptionsperceptions and and thinking about what thinking about what they experiencethey experience. They learn by . They learn by

copying copying the examples of others around themthe examples of others around them

2 sets of expectations:2 sets of expectations: Outcome expectationsOutcome expectations – behaving in a certain way will – behaving in a certain way will

produce a particular outcomeproduce a particular outcome Efficacy expectationsEfficacy expectations – belief that the person has the – belief that the person has the capacity to produce successfully the behaviour necessary capacity to produce successfully the behaviour necessary

for achieving the desired outcomefor achieving the desired outcome

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Problems with basic learning theory - BanduraProblems with basic learning theory - Bandura

Difficult to always define what a person’s Difficult to always define what a person’s performance expectations are without close performance expectations are without close observationobservation

May have distorted view of our own efficacy – “I’m May have distorted view of our own efficacy – “I’m just no good at writing essays”just no good at writing essays”

Nevertheless, we can see where the change Nevertheless, we can see where the change emphasis needs to be on reinforcement of positive emphasis needs to be on reinforcement of positive thoughts to achieve desired outcomes thoughts to achieve desired outcomes

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What is Cognitive Behavioural Therapy?What is Cognitive Behavioural Therapy?Let’s start with a basic observation of an emotive episode that may happen to any of usLet’s start with a basic observation of an emotive episode that may happen to any of us

Three elements:Three elements:AA What starts it off?What starts it off? ANTECEDENT/ACTIVATING EVENTANTECEDENT/ACTIVATING EVENTBB Beliefs about BBeliefs about B BELIEFSBELIEFSCC Reaction Reaction CONSEQUENCECONSEQUENCE

ExampleExample

AA Friend passes us in street & ignores usFriend passes us in street & ignores usBB “I’m not worth acknowledging”; “nobody gives a s…”; “seen as “I’m not worth acknowledging”; “nobody gives a s…”; “seen as

worthless as a friend…therefore as a person”worthless as a friend…therefore as a person”CC FeelingsFeelings - lonely and depressed - lonely and depressed BehaviourBehaviour – withdraw into self – withdraw into self

So at root CBT is about:So at root CBT is about:

How you think about yourself, the world and other peopleHow you think about yourself, the world and other people How what you do affects your thoughts and feelingsHow what you do affects your thoughts and feelings

Self ActionSelf ActionUnhelpful – Go home and avoid this friend and othersUnhelpful – Go home and avoid this friend and others

Helpful – get in touch and see if they are okHelpful – get in touch and see if they are ok

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Related and building on learning theory – Related and building on learning theory – Cognitive Cognitive Theory and Behavioural Work - CBTTheory and Behavioural Work - CBT

There are a range of related theories here – see Payne pp There are a range of related theories here – see Payne pp 121-123 – see also slide 19121-123 – see also slide 19

Cognitive theory is basically suggesting that as behaviour is Cognitive theory is basically suggesting that as behaviour is affected by affected by perception or interpretationperception or interpretation of the environment of the environment

during learningduring learning

Inappropriate behaviour must be a Inappropriate behaviour must be a misperceptionmisperception

The interesting issue here is that behavioural therapies or The interesting issue here is that behavioural therapies or CBT are discussing altering CBT are discussing altering disorders in thinkingdisorders in thinking – in the – in the

MIND – MIND – when as we saw above initially behaviourism only when as we saw above initially behaviourism only focussed on behaviourfocussed on behaviour

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ABCs – Antecedent; Beliefs; ConsequenceABCs – Antecedent; Beliefs; Consequence

We can see that the basic tool deriving from these approaches for We can see that the basic tool deriving from these approaches for practical work by psychologists & social workers is this use of A, B, practical work by psychologists & social workers is this use of A, B,

CsCs

In terms of a basic tool kit that has a hands on utility – then these In terms of a basic tool kit that has a hands on utility – then these behaviour therapy approachesbehaviour therapy approaches are now widespread in are now widespread in

contemporary NHS and social care workcontemporary NHS and social care work

Widespread use in work on:Widespread use in work on:

Stress/anxiety; depression; addictions; panic; agoraphobia & other Stress/anxiety; depression; addictions; panic; agoraphobia & other phobias, social phobia, bulimia, obsessive compulsive disorder; post phobias, social phobia, bulimia, obsessive compulsive disorder; post

traumatic stress disorder and, now, in some cases schizophreniatraumatic stress disorder and, now, in some cases schizophrenia

Huge recent investment by NHS – see belowHuge recent investment by NHS – see below

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Classification…4 types of cognitive-behaviour Classification…4 types of cognitive-behaviour therapies – according to Scott & Dryden (1996)therapies – according to Scott & Dryden (1996)

Coping SkillsCoping Skills – 2 elements self verbalisation (instruction – 2 elements self verbalisation (instruction to ourselves) & changes to environment e.g. stress to ourselves) & changes to environment e.g. stress reduction - reduction -

Problem solvingProblem solving – cf Perlman’s psycho-analytic work – – cf Perlman’s psycho-analytic work – see life as a process of resolving life issues lock onto a see life as a process of resolving life issues lock onto a problem generate a no of solutions – get client to choose problem generate a no of solutions – get client to choose best for thembest for them

Cognitive restructuringCognitive restructuring – particularly used when – particularly used when people are unreasonably negative – ‘awfulising’ – as Ellis people are unreasonably negative – ‘awfulising’ – as Ellis calls it in his rational-emotive beh.therapy calls it in his rational-emotive beh.therapy technique…..irrational beliefs at the root of people’s technique…..irrational beliefs at the root of people’s problems e.g. lorry driver – see belowproblems e.g. lorry driver – see below

Structural cognitive therapy Structural cognitive therapy – concerned with 3 – concerned with 3 ‘structures’ of belief - ‘structures’ of belief - corecore beliefs; beliefs; intermediateintermediate beliefs or beliefs or explicit descriptions of the world; and explicit descriptions of the world; and peripheralperipheral beliefs. beliefs. The later are used as become the immediate target of The later are used as become the immediate target of action but the aim is to alter the other twoaction but the aim is to alter the other two

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Ellis’s ABCDE theory of emotions – Ellis’s ABCDE theory of emotions – cognitive re-structuringcognitive re-structuring

AA Activating eventActivating event of situation – wife dies of situation – wife dies unexpectedlyunexpectedly

BB BeliefsBeliefs – self defeating belief – “my fault – self defeating belief – “my fault should should have called GP earlier”!have called GP earlier”!

CC ConsequencesConsequences – emotional/behavioural – emotional/behavioural - “I - “I deserve to suffer/be depressed/don’t deserve to suffer/be depressed/don’t need/deserve need/deserve helphelp

DD DisputationDisputation – challenge irrational belief and – challenge irrational belief and replace with rational – “you did right and do not replace with rational – “you did right and do not have power over life and death.”have power over life and death.”

EE EvaluationEvaluation – goes alongside D – so that the client – goes alongside D – so that the client reappraises the A, B, C processreappraises the A, B, C process

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Effectiveness of CBTEffectiveness of CBT

StrengthsStrengths

Evidence based practice - & examples of Evidence based practice - & examples of success in certain contexts i.e.with success in certain contexts i.e.with addictions & stressaddictions & stress

Relatively easy to use – but need to know Relatively easy to use – but need to know techniques well & have good listening & techniques well & have good listening & presentational skillspresentational skills

Widely applicableWidely applicable Time limitedTime limited

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Possible Problems with Use of CBT:Possible Problems with Use of CBT: Can be a long process – 5 to 20 one hour sessionsCan be a long process – 5 to 20 one hour sessions Favourable outcomes when compared to no intervention Favourable outcomes when compared to no intervention

or on subjects who select this therapy through public or on subjects who select this therapy through public advertisements – much less so on random clinical advertisements – much less so on random clinical selectionselection

Example - used a great deal for depression but in Nat Example - used a great deal for depression but in Nat Inst of Mental Health Study of depression – CBT fared Inst of Mental Health Study of depression – CBT fared less well than interpersonal therapy or GP management less well than interpersonal therapy or GP management with anti-depressantswith anti-depressants

Can be difficult for some patients to verbalise their Can be difficult for some patients to verbalise their feelingsfeelings

Does not really address the causes of problemsDoes not really address the causes of problems Danger when CBT is used for clients that have more Danger when CBT is used for clients that have more

complex underlying psychiatric disturbances e.g. anger complex underlying psychiatric disturbances e.g. anger management progs in prisonsmanagement progs in prisons

Increasingly seen as a panacea in treating certain Increasingly seen as a panacea in treating certain conditions cheaplyconditions cheaply

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ConclusionConclusion

Very wide influence in & around social work – particularly, Very wide influence in & around social work – particularly, but not exclusively, in mental health settingsbut not exclusively, in mental health settings

Usually used by social workers in a stripped down form Usually used by social workers in a stripped down form around ABCsaround ABCs

Fits in with task centred, focussed approaches planned, Fits in with task centred, focussed approaches planned, clear agreed goalsclear agreed goals

Many elements of the practice can show empirical Many elements of the practice can show empirical validated successvalidated success

Continues to generate some concerns due to its overly Continues to generate some concerns due to its overly technical rational scientific nature, certain ethical issues & technical rational scientific nature, certain ethical issues & occasional inappropriate applicationoccasional inappropriate application