What is a systematic approach in CBT? - Chapter 6

What is this chapter about?

CBT is by definition a very dynamic collaborative process in which the therapist and the client jointly create insight into how the current problems have arisen and how they are maintained. This insight – the wording – is often written down, but can also be conveyed verbally. It explicitly mentions the links between the "four response systems" (cognitive, emotional, behavioural and physical) in the current problem situation and it explains how these responses are related to the underlying beliefs about the self, about others and about the world. Every stressful situation elicits a response in each of the domains. This formulation is gradually built up by Socratic dialogues to promote a guided discovery in which the therapist only accompanies the client. The client thus finds out not only the vicious circles in his or her life that cause or sustain the problems, but also thinks about his or her own strengths and resources. When CBT is used for children (under 18) it is essential to also include the developmental, attachment and family, contextual and cultural factors in order to meet the unique needs of each child. Pragmatically, primary physical and emotional safety must also be met before trying to address the "higher processes".

What is the traditional structure of individual CBT treatments?

Clients learn to understand how a response in one system may affect elements in other systems, leading to a disproportionate magnification of symptoms. In the treatment, the client is as actively involved as possible.

Which CBT treatment structures suit children, families and the wider system?

Many psychologists try to simplify the model of the “four response systems” of CBT when they want to use it in children. However, it is essential that, after simplification, all four systems are still involved! When using CBT in children, a systematic approach should also be employed. In other words, the child's system (parents, siblings and the wider system such as school, hobbies and boyfriends, girlfriends) should also be considered. The child is central to this (see an example of such a systematic CBT treatment structure in the figure in the book). The direct complaints, wishes, thoughts, emotions and behaviours of the most involved persons in the immediate proximity of the child (usually the parents) and any major life event, which may have helped to shape the child's underlying beliefs, are therefore also incorporated into the formulation of the problem. Thus, the child and the parents are asked to formulate a problem list: what do you think are problems and how serious do you think they are? They are also asked: What are the changes you're hoping for? This explicitly highlights the differences in problem perception and reveals the motivation for change. This structure is never presented to the child in all its complexity at once. Nevertheless, this is the starting point of the treatment. This is always a gradual process and proceeds in accordance with the child's level of development.

Processing development, insights from other psychotherapies and adhesion processes in the formulation

Developmental problems and biologically intrinsic difficulties are also included in the formulation. Here it is always important to emphasize and encourage the strengths and attempts of the child to improve something. In the case of a child with ADHD, the primary defect, in child A, for example, is the impulsive behavior, can be identified together with other perpetuating or strengthening factors such as parental cognitions or behaviors. Unrealistic expectations and the consequences of this can therefore also be mapped. Due to the dynamic and empirical nature of the formulation, this is by definition an integrative approach, incorporating insights from other psychotherapies. Attachment-related factors can also be reflected in the formulation, through observation of attachment-related behaviors and affect – which are mediated  by cognitions – on each of the four systems and from there, among other things, address selective perceptions, unrealistic expectations, assumptions and the standards of the parents.

What is meant by four systems?

To this day, there is little scientific evidence that can tell us for which populations and clinical patients systematic CBT interventions are effective. Therefore, the practitioner has to assess this on a case-by-case basis.

Systematic CBT is always based on the four systems. Self-reflection and guided discovery are both strongly stimulated by the use of Socratic dialogues and empirical research (including recent event analysis). There are four possible applications of the systematic CBT:

1. Only with the child (individual): In the case of such individual sessions it is important to help the child change their focus, because they often enter the room with a very internal focus (e.g. guilt). Many systematic factors can be well mapped by the child himself, which can then serve as the basis for family sessions.
2. With the child and the parents/carers: Parents can be involved in therapy as mediators, co-therapists or as clients (see Chapter 7). Pragmatic factors and the formulation determines which role is appropriate.
3. With the whole family: Socratic recent events analysis of both recent problems and recent positive events form the basis of a systematic CBT treatment in which the whole family works together. To ensure that the family members drop their natural defence mechanisms, there must be a trusted and safe therapeutic relationship. In this way, all perspectives and problems can be discussed, with which constructive work can be done. Everyone is asked to reflect on their own and other people's experiences and reactions. It must be remembered that the emphasis is not only on person who should change!
4. With the broader system: This helps to when multiple organizations are involved. Involving all of these organizations can help to improve the child’s outcomes.

Integrating developmental factors, attachment factors and family and wider system factors into CBT treatment for children, young people and families has many advantages, as it helps children and families to (better) understand things and discover the possibilities for change.

CBT is by definition a very dynamic collaborative process in which the therapist and the client jointly create insight into how the current problems have arisen and how they are maintained. This insight – the wording – is often written down, but can also be conveyed verbally. It explicitly mentions the links between the "four response systems" (cognitive, emotional, behavioural and physical) in the current problem situation and it explains how these responses are related to the underlying beliefs about the self, about others and about the world. Every stressful situation elicits a response in each of the domains.