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Cognitive and behavioural techniques: segregation or integration?

Although behavioural and cognitive techniques stem from different theoretical backgrounds (behaviour therapy from learning theories and cognitive therapy from information processing theories), in practice they are inextricably bound because any changes in behaviour may influence one’s thinking and any changes in thinking are usually reflected in one’s behaviour. Let us take, for example, the task of asking someone to confront an anxiety-provoking situation with the aim of controlling and reducing their symptoms of anxiety. This therapeutic activity (i.e. confrontation of an anxiety-provoking situation) which leads to the same outcome (i.e. reduction in anxiety) has a different name and a different working mechanism depending on whether we consider it within a behavioural or a cognitive perspective.

A behavioural explanation would use habituation as the anxietyreduction mechanism, would call the anxiety-related thoughts feared consequences and would term the treatment activity an exposure task. A cognitive explanation would describe anxiety-related thoughts as catastrophic beliefs, would consider the disconfirmation of catastrophic beliefs as the anxiety-reduction mechanism and would term the treatment task a behavioural experiment. In practice, it is virtually impossible to differentiate what brings about the reduction in anxiety; whether it is that people get used to it over time (as in behaviour therapy’s habituation) or whether it is that they no longer believe that something terrible may happen (as in cognitive disconfirmation). Therefore, the same activity used as part of a cognitivebehavioural treatment may be explained with both a behavioural and a cognitive rationale without substantial differences in its practical delivery and outcome. Having established the crossover between behavioural and cognitive techniques, it is also important to highlight some of their dissimilarities in the way they are delivered and the emphasis they lay on different aspects of treatment.

Behavioural techniques are mainly focused activities which aim to change people’s pattern of responses to external and internal stimuli. These responses are the result of acquired strong associations and positive or negative reinforcement. The application of behavioural techniques is symptom-driven and depends on delivering the right technique for the right problem. In contrast, cognitive techniques use both guided dialogues and focused activities in order to change thinking processes and beliefs which are considered the mediating factors between people’s experiences and their emotional state or reactions.

Cognitive techniques place great emphasis on the process of therapy and their application is guided by an individualized case formulation irrespective of diagnostic classifications relating to the problem. In summary, behavioural techniques are symptom-driven activities which explain treatment outcome in terms of learned responses, whereas cognitive techniques are process-focused dialogues and activities which explain treatment progress in terms of belief change. In practice, it is usually difficult to distinguish whether it is the behavioural or the cognitive mechanism which produces the reduction in the symptoms, distress and disability associated with a mental health problem. Investigating the differential effect of behavioural and cognitive components of CBT could lead to more efficient treatment models and specific guidelines about which techniques may suit what patients.

Whether segregated or integrated, behavioural and cognitive techniques should always be considered within the wider framework of patient care which involved the interpersonal effect of clinician input, the need for risk assessment and management, and the benefits of medical, social, family and psychological interventions other than CBT.

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