June 19, 2023

The evolution of therapy

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As promised, this week Cass gives us a little history lessons in modern psychology and the evolution of therapy over the last 30-40 years. We've certainly come a long way since the days of reward or punishment. But what are the modern approaches and how has therapy evolved throughout recent decades?Cass explains what Cognitive Behaviour Therapy (CBT), and Acceptance and Commitment Therapy (ACT), are and how these approaches fit within modern advances in neuroscience and nervous system regulation. She also explores the role of mindfulness and meditation, and the role of somatic therapies (like EFT, and EMDR), breathwork and yoga.
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Transcript

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A listener production. This is Crappita Happy and I am

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your host castunn. I'm a clinical and coaching psychologist and

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mindfulness meditation teacher and of course author of the Crappita

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Happy books. In this show, I bring you conversations with interesting, inspiring,

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intelligent people who are experts in their field and who

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have something of value to share that will help you

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feel less crappy and more happy. Welcome to another solo

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episode of Crappya Happy. And as I mentioned in my

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last solo episode, today, what I wanted to talk to

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you about was the different approaches to therapy. And I

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guess a little about how therapeutic approaches have evolved over

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the past ten, twenty thirty fifty years without going too

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much into the long history of the practice and profession

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of psychology, but I do know that some people get

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confused about terms like CBT and ACT and how these

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things work together and what's the best? Is there one better?

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So let's just have a little run through of what

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you might expect from these different approaches to therapy. So

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to go back a little into the history. In the

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early nineteen hundreds, you've probably heard of a guy called Skinner,

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BF Skinner. You probably heard of Pavlov, these approaches around

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kind of operant conditioning, behavioral approaches to therapy. I guess

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essentially all that means is that psychologists at that time

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believed that all behavior was based on approaching a reward

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or avoiding a punishment, and that if you rewarded a behavior,

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you would see more of it. If you punished a behavior,

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you would see less of it. Give the dog a

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treat while you ring a bell and eventually you just

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ring the bell and the dog salivates expecting the treat.

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The way our brains respond to reward and punishment, that

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was obviously kind of problematic at the time. It was

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very limited, and you know that it was the dominant

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kind of idea at the time, and so to the

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point where, for example, even little children who had to

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be hospitalized, they discouraged parents from visiting because when parents visited,

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the babies would cry, and so to reduce the crying,

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they just didn't allow the parents to visit. Like there

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was no concept, There was no consideration given to the

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internal world of those infants, of what was going on emotionally.

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It was all just focused on behavior. We want that

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behavior that irritating, annoying behavior to stop. Therefore, we will

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not reward the behavior by picking up the child. That

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was kind of the thinking at the time. You make

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a rod for your back. If you reward the behavior

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by giving the child nurturing or attention, then that behavior

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will continue. So if you want to extinguish it, then

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you just ignore it. Highly problematic given what we know

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now about human attachment and our emotional world. So fast

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forward to I guess the fifties was when John Bolby

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really became interested in attachment theory. No surprise that our

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no coincidence that John Bolby was raised by a very

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emotionally detached English father, so he was quite interested in

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the internal world of children and individuals. So we learned

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a lot from the likes of Bolby and his colleagues.

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But I guess from a psychological perspective, it was also

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around that time that people started to consider the idea

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that our internal world, our thoughts, and our feelings also

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had an influence on our choices and our behaviors. So

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people like Albert Ellis Aaron Beck came up with the

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first conceptions I guess of a cognitive approach to therapy

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and the idea that if you think a different way,

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that you will feel a different way, and that you

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might make a different choice or change your behavior in

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some way, and that really became the dominant and kind

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of approach and paradigm for quite a while, even until

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now until very recently. Cognitive behavioral therapy therapies that approach

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changing your thinking in order to change your emotional response

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and therefore change your behavior and also changing what you do.

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So cognitive is the thinking, behavior is the doing, so

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also doing things differently. For example, if you are had

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a phobia, for example, then approaches like exposure therapy, you know,

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putting you in the position of doing the behavior, gradually

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introducing you gradually to things that you are afraid of,

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to desensitize you to that stress and fear response so

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that you can gradually do more and more. So that's

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the kind of behavioral approach that would include even things

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like if you are feeling socially withdrawn, feeling like you

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don't want to leave the house, then doing something different,

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going out and doing something different, because then that will

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give you a different experience and that will change the

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way you think and feel. So that's CBT. Basically, if

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you if you now were to see a therapist and

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their approach was a CBT, a cognitive behavioral approach, which

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has been the dominant paradigm that's been considered to be

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the gold standard in psychological therapies and therapeutic approaches for

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quite a while, particularly in the treatment of anxiety and depression.

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Very common commonly experienced psychological struggles. I guess, then that's

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what's happening. It's what what's the what's the thought, what's

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the story that you're telling yourself? How does that make

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you feel? Like? What? What emotional response do you have

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when you think that thought? And then what does that

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cause you to do? What's the consequence? And a very

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typical exercise that we might ask a client to do

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using a CBT approach is that exact process, what happened?

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What did you tell yourself in response to what happened?

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Because our brains are meaning making machines, so no matter

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what happens, we are interpreting it, We applying our own

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filters and prejudices and his personal history, and even the

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mood that we're in is overlaid over the top of

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our experience, so we're making meaning of things that are

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inherently subjective. They're not actually often rational or objective. So

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we make meaning of that, and the base of the

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meaning that we make, we will feel a particular way

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about that experience, and then that will often directly influence

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how we choose to respond, what we choose to do next.

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So if we can target the unhelpful thinking, and if

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we can start to consider that there are different perspectives,

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there's a different way potentially of looking at this situation.

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What is the meaning that we made of that? Is

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there any evidence for that? Is it helpful? Is there

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a potential other perspective we could apply? And then how

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would that feel? How would that change my experience? And

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then what might I do differently as a result or

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in response around about the I'm going to say the

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nineteen nineties I should know this. It was in the

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nineteen nineties a group of psychologists who were tasked with

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finding an alternative to CBT for treatment resistant chronic depression.

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What they found was that people had chronic So depression

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is a chronic condition for most people. If you've had

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an episode of a major depressive episode once, you are

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statistically more likely to experience depression again. If you have

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been depressed twice, then you are kind of exponentially more

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likely to experience depression a third time. So if you

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have a history of depression, then it's really important to

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be managing your lifestyle, managing your mood, managing you know,

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being aware of early warning signs, having those strategies and

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that toolbox to recognize when you might be slipping down

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that path again, because it is more likely to reoccur

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for you. And these psychologists found that they give people

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CBT and they improve somewhat, and then they relapse, and

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then you put them through a course of CBT again

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and again. It short term effectiveness, but it's not lasting.

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The results aren't sticking. So they really wanted to find

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an alternative approach, and around that time they came across

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this guy, John Cabotsin, who had been teaching. He'd created

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this program which he called MBS Mindfulness based Stress Reduction

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in the late seventies early eighties. He was using it

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to help people who were experiencing treatment resistant chronic pain,

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physical pain, and what he found was that if he

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taught them mindfulness. He had a background in zen Buddhism.

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He was a biologist, so not a psychologist, not a doctor.

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But he found that if he taught them basic mindfulness exercises,

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and mindfulness was being able to observe what is happened

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as it's happening, without judging it, so to observe experiences

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of physical pain in the body and be curious about

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that pain instead of resisting, embracing and judging and wanting

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it to be gone. And because all of that experience,

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that emotional experience of resisting and tensing was only making

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the pain worse, so he taught people basic body scan meditations.

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Lie down, track your body. Where do you feel a sensation?

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How can you be curious about that? Can you explore?

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Where does it start? Where does it stop? How would

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you describe that sensation? So he taught them to be

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curious and accepting as opposed to fighting and resisting and

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struggling against their chronic pain. And what he found was

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that people's experience of pain reduced, the severity and the

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intensity reduced. So it wasn't that the pain necessarily went away,

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although it possibly did a little if they stopped resisting,

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but it was that their relationship with the pain changed.

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There was less struggle and there was more acceptance, and

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I guess a willingness to just allow it to be

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there and to relate to it just as a sensation, because,

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in the words of John Cabotsinn, what other choice did

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they have. The pain was going to be there anyway,

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So why make it worse than it needs to be

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by going to battle with it mentally and physically. So

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back to our three psychologists, teased Siegel and Williams were

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their names surnames. They approached John Capetsinn and said, we

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think this is a really curious idea and we would

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be really interested to see how this would work with

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people who have emotional struggles psychological struggles that they are

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struggling to overcome. And so John Cabotsn told them that

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they would need to do the course. They would need

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to learn mindfulness themselves, to have an understanding, a direct

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understanding of the experience of mindfulness and what that is

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like before they could teach it to anybody else. I

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think they are a little resis to that idea actually,

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But nevertheless, they did his program, they learned about mindfulness,

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and then they took it to people with treatment resistant

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chronic depression, not who were currently depressed, but who were well,

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but who had a history of chronic depression. And they

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taught them the exact same thing, when you observe your experience,

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your low mood, instead of resisting that, fighting that I

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wish this wasn't like this? Why can't I change? Why

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won't this go away? Not this again? What's this going

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to mean? Am I going to have to take time off?

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Is my partner going to reject me? All of that

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mental struggle that goes along with a low mood because

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of the association they have with what it means to

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be depressed in their past experience and all of these layers.

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If they could just observe that as a low mood,

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get curious about it, but remove all of the layers

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of meaning and judgment and resistance and just allow that

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to be there, what they find was that the mood

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passed more quickly. So that is how we developed they

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developed mindfulness based cognitive therapy because it still was a

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way of targeting thoughts, targeting the internal world, but not

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in I have to find the bad thought. I have

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to fix the thought, change the thought, think something different.

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What's wrong with me for thinking this thought? You know? Really? Again,

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it's that like active resistance of your experience instead of

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just being able to observe and allow it to be

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what it is and just remove all of the judgment

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and remove all of the struggle, just drop the struggle.

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And this had results, so mindfulness based cognitive therapy. In

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the early trials, they found that it reduced the relapse

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rate for people with a history of chronic depression by

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as much as fifty percent. In fact, there are trials

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that that show it is as effective as medication for

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treatment people with the history of depression. And since then,

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like that was back in the nineties, and obviously since

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then there have been many, many, many many research studies done,

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many clinical trials. Mindfulness has been found to be effective

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in a whole range of emotional psychological struggles as well

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as a whole bunch of physical conditions as well. But

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that is the basic premise of what mindfulness is. I

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think it's fair to say now that even though at

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the time mindfulness was a different approach to standard CBT,

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to a standard cognitive therapy approach in the ways that

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I have just described, I think now you'd be hard

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pressed to find a cognitive therapist who doesn't use some

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form of mindfulness in their practice. I think the research

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is so solid. I think it's just so widely known

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and understood now how beneficial mindfulness is for managing uncomfortable

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inner experiences, painful thoughts, uncomfortable feelings. This idea of being

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able to be with those experiences, to allow those experiences

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to not have to fight or change or resist, or

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for anything to be different from what it is. I

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think that's pretty pretty widely understood. So I don't think

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that's necessarily a divide now. I maybe there are some

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therapists out there who do straight cognitive therapy and they

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not really interested mindfulness, but I don't know too many

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of them. I think that everybody kind of gets that now.

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So NBCT is an eight week program that you can

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tell I'm trained in MBCT. I've taken people through an

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MBCT course. I adapted it to become Mindfulness for Busy People,

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which is my online course which anybody can sign up

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for and do at home. I just shortened it and

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made it a six week program which you can take

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in the comfort of your own home. And it was

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my way of trying to make that idea, make mindfulness

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more accessible to people who perhaps couldn't drive and park

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and take time out of their week to go and

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sit in a room for eight weeks in a row.

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I wanted to make it much more accessible, but still

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retain the basis of what that course is about, what

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it is designed to teach you. You can sign up

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for that anytime you like. It's available on my website.

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So I say that I need to distinguish NBCT just

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from general sort of mindfulness interventions. And there are a

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range of mindfulness based interventions and programs you can take,

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or if you're seeing a therapist, you will no doubt

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have them introduce some form of mindfulness and mindfulness activity.

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And that is the reason why, because it is so effective.

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There is another approach to therapy which is also a

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mindfulness based approach, and it is called ACT. Don't, for

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the love of God call it ACT. The founders, the

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people who generated and created Acceptance and Commitment Therapy ACT,

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they don't like you to call it ACT. They get

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really offended by that. I don't know why, but whenever

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I hear somebody say ACT, you would not want what

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was his name, Stephen Hayes, who developed ACT to hear

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you calling it act. I don't know why don't call

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it a CD. So Acceptance in commitment therapy is an

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approach developed by, like I said, Stephen Hayes and around

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the same time I guess the eighties nineties, but it

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really didn't come into really didn't get picked up a

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lot until I'm going to say the two thousands, which

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is when I was doing my training. He developed this

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approach called acceptance of commitment therapy, which basically is founded

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on six core processes, which he says are to a

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designed to promote psychological flexibility. Those six processes I can

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run through them. One is acceptance. That's exactly what I

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was just talking about in relation to mindfulness. It is

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this idea of accepting and embracing the full range of

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human emotions without having to resist or fix or change anything.

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That's fundamental to act. He says, basically, why if all

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humans feel all emotions, why do we say this one

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is bad and we should try to not feel it

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with basically pasologizing the human condition. And yes, clearly sometimes

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you know, depression and anxiety there can be debilitating and

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obviously we want to reduce the severity of those symptoms

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and the pain of that experience, but generally speaking, he says, well,

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why can't we just learn to be more accepting and

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more tolerant and more comfortable with being uncomfortable sometimes, which is,

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you know, not a bad thought. Then he has cognitive diffusion,

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which is a way of like I call it, kind

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of like unhooking. And that's this idea of being able

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to again observe your thoughts without being so consumed by

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your thoughts. Again, that's mindfulness. That's just being able to

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witness a thought and just witness it, observe it, let

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it go without having to be in your thoughts, in

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your head, wrapping yourself around the thought. You know what

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it's like when you have a thought and you're just

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you're in it and you are consumed by it. We

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believe everything we think, we think, we've got to act

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on every thought that we have. We're hijacked by our

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thoughts all day. So he says, can we just unhooked?

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Can we just witness thoughts? And he's got all sorts

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of kind of funny exercises he does to help you too,

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take your thoughts less seriously, you know, do it in

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a sing song voice. Sound, listen to your thoughts like

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a Mickey mouse's voice or whatever. His other one is

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being present, So being present lo and behold mindfulness. So

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that again is about observing, you know, being fully present

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in your experience, observing without judgment. He's got this idea

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of self as context, which is an idea that is

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that we are more than This is kind of this

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transcendence kind of approach. This is about we are more

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than our thoughts, We are more than our ego. There

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is a part of us that is bigger, so can

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we It's almost like transcending the human experience. And then

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here's the key with act. The final two processes values

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knowing what you stand for, knowing what matters to you,

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and committed action, taking action that is in alignment with

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what matters most to you. If I were to sum

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this up this whole approach, essentially, it is instead of

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trying to reduce suffering, instead of trying to get through

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your life without struggle and pain and discomfort, how about

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know what matters to you, take action that is aligned

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with what matters most to you, even if it's uncomfortable,

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and be willing to tolerate that discomfort because it is

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in the service of something important to you and your life.

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So this is much less about let's reduce suffering, let's

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fix depression, let's fix your bad mood, let's never experience

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an uncomfortable emotion. It is much more more about what

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is does a full reach, meaningful life look like for you,

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and how can you live it even if it means

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that you've got to do things that are a little uncomfortable. So,

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as an example, that might be in relationships, you've got

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to put yourself out there and risk rejection because that

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matters to you to have a relationship, as opposed to

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I can avoid all of that by just staying at home.

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So it talks a lot about experiential avoidance, as in

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avoiding experiences that feel uncomfortable and taking a different approach

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and being able to move towards what feels uncomfortable, but

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knowing that it is for good reason, because it's about

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living a life that is meaningful to you. So that

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is ACT in a nutshell. And you know, when I

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was doing my training, it was CBTCBTCBT, and I was

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ACT ACT because that really was much more aligned with

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my own views and just intuitively made more sense to me.

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So I was very fortunate to have supervisors who were

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also predominantly ACT therapists who were able to support me

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in that. But you know, the standards of training for

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psychologists were that evidence based approach. The gold standard was CBT. Again,

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I would say now that many many therapists, even if

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they are not, even if they don't call themselves an

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ACT therapist per se, and I don't, actually they probably

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are drawing on elements of ACT in their work with clients. Again,

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just because it makes sense and because there's so much

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evidence to support it, I'm going to say that I

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think many many therapists, if you use to talk to

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them now, they probably really do take out a bit

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of an eclectic approach. They're probably drawing on elements of

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all of these approaches and doing what is right for

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the client, for the patient, And that would be certainly

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what I would do. But certainly everything that I do

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has a foundation. And I don't actually do therapy anymore

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because I live in the UK, you guys, so I'm

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not registered to practice here. But I even in my

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coaching and everything that I do, it has a fundamental

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foundation in mindfulness and acceptance as opposed to let's look

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at your thoughts and change your thoughts and fix those

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thoughts and think different thoughts and use that as the

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basis for changing your experience. Try not to think about

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a pink jeep, you know, for the next five minutes,

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don't think about a pink jeep. We can see how

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effective that is or not, because if I statistically in

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the research would demonstrate that if I tell you not

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to think about a pink jeep for the next five minutes,

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not only will you have more thoughts of pink jeeps

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in the next five minutes than you would have, but

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you will have random thoughts of pink jeeps for the

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next twenty four hours. It will keep popping up into

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your head. And I apologize that now you're going to

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keep thinking about pink jeeps. That's essentially the problem with like,

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don't think that thought or think a different thought. So

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that's act CBT kind of the where they sit and

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what their basic approach is. I'm going to say that

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I think we've even evolved further now and I'll keep

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this really short, but you know, we really understand now

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the role of the nervous system. Stephen Porge's developed a

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polyvagal theory which is about how the nervous system acts.

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It's all connected to your fire flight, freeze response and

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also your social engagement systems, So it's about how you know.

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A CBT approach essentially is what we call a top

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down approach. It says, you change your thoughts and you

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will change your internal experience, you will change your feelings,

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you will change what's happening in your body, like you'll

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calm down. That nervous system we know now is actually

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that in terms of that brain body kind of connection,

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that eighty percent of communication is from the body up.

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So your nervous system is responding to micro signals so

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that you're probably not even consciously aware of in the

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