Understanding cognitive behaviour therapy: A retrieval competition account

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Abstract

Vulnerability to emotional disorders is thought to lie in memory representations (e.g. negative self-schemas) that are activated by triggering events and maintain negative mood. There has been considerable uncertainty about how the influence of these representations can be altered, prompted in part by the development of new metacognitive therapies. This article reviews research suggesting there are multiple memories involving the self that compete to be retrieved. It is proposed that CBT does not directly modify negative information in memory, but produces changes in the relative activation of positive and negative representations such that the positive ones are assisted to win the retrieval competition. This account is related to the treatment of common symptoms typical of emotional disorders, such as phobic reactions, rumination, and intrusive images and memories. It is shown to provide a parsimonious set of principles that have the potential to unify traditional and more modern variants of CBT.

Introduction

The foundations of cognitive-behaviour therapy (CBT) have been the challenging and modification of irrational ways of thinking and dysfunctional ways of behaving. Its procedures formalised in detailed treatment manuals and its outcome evaluated in randomised controlled trials, CBT has been extremely successful and is now a favoured therapy for a wide variety of conditions (e.g. Hollon & Beck, 2003; Roth & Fonagy, 2005). What is still controversial is how it brings about change, and whether the different types of procedure used in CBT utilise similar mechanisms. In this article I review the theoretical basis of CBT and propose that it should be understood in the context of multiple representations in memory, some positive and some negative, that compete for retrieval. In the acute phase of an emotional disorder negative representations are highly accessible, with intrusive memories, self-depreciating interpretations, and ruminative thoughts dominant. CBT procedures involve the selection and creation of alternative representations that are assisted to win the retrieval competition and restore more positive mood states. This approach is evaluated against several criteria such as utility and parsimony, and the wide-ranging clinical implications discussed.

Why, if CBT is so successful, is it necessary to question its theoretical basis? First, therapeutic techniques such as desensitisation or exposure were based on behaviourist theories that have largely been superseded by more sophisticated approaches to associative learning in animals and humans (Mineka & Zinbarg, 2006). Similarly, the philosophy of cognitive therapy is largely rooted in the assumptions of the 1960s and 1970s. It is now possible to draw on a much more extensive empirical and theoretical understanding of learning and cognition than was available at that time. Second, reviews have concluded that CBT, while effective, does not always lead to clinical improvement and does not always protect successfully treated patients against relapse (Robinson, Berman, & Neimeyer, 1990; Roth & Fonagy, 2005). Hence, by clarifying the mechanisms by which CBT brings about change, it may be possible to improve outcomes. The third reason is that cognitive therapy is itself developing in new directions. There is a greater emphasis on metacognitive interventions that attempt to change a person's relationship to their negative thoughts rather than directly challenge the content of those thoughts (e.g. Hayes, Strosahl, & Wilson, 1999). Other interventions seek to introduce positive distortions into cognitive processes, for example by manipulating imagery (e.g. Hackmann, 1998; Smucker, Dancu, Foa, & Niederee, 1995). These approaches appear on the face of it to be challenging some of the original assumptions of CBT.

Fig. 1 presents a generic version of the cognitive model of emotional disorder underlying CBT, adapted from Beck (1976), Beck, Emery, and Greenberg (1985), Foa and Kozak (1986), Harvey, Watkins, Mansell, and Shafran (2004), Wells (1997), and others. Over the years the generic model has been developed and applied to various disorders including depression (Beck, Rush, Shaw, & Emery, 1979), panic disorder (Clark, 1986), posttraumatic stress disorder (PTSD: Ehlers & Clark, 2000; Foa & Rothbaum, 1998), hypochondriasis (Warwick & Salkovskis, 1990), obsessive-compulsive disorder (OCD: Salkovskis, 1985), generalised anxiety disorder (Riskind, 2005), and social phobia (Clark & Wells, 1995). Although many of these models focus primarily on the different maintaining processes, they generally assume that previous adversity produces vulnerability in the form of negative representations of the self and the world (the most widely used term for such representations being ‘negative schemas’). Triggering events lead not only to negative mood states but, in interaction with these representations, to the intrusion of negative thoughts and images that prolong negative mood. Altering the processes that maintain these thoughts and images improves mood immediately but, in the longer term, must also reduce the likelihood of problematic representations being activated in future.

The focus of this article is on the critical issue of how overcoming behavioural and cognitive avoidance, challenging negative thoughts, or modifying maintaining processes affect the memory representations that carry vulnerability to future episodes of disorder. Barber and DeRubeis (1989) discussed this in the context of cognitive therapy for depression. Their accommodation model corresponds to the widely accepted view (Beck et al., 1979; Foa & Kozak, 1986) that therapy modifies the structures in memory that give rise to negative beliefs. That is, successfully correcting irrational thinking or behaviour directly alters the content of the schemas that carry vulnerability and reduces the risk of relapse. In contrast, their activation–deactivation model proposes that therapy does not change structures in memory but leads to the deactivation of negative memories and the activation of positive ones.1 These models have been further elaborated by Kwon and Oei (1994). Brewin (1989) proposed more specifically that it is the creation of competing memories in therapy that deactivates or blocks access to problematic representations. Thus, both Brewin (1989) and Barber and DeRubeis (1989) were concerned with whether problematic memory representations were directly modified or simply deactivated. This apparently simple question has important implications for understanding and designing interventions within CBT.

Before proceeding further, it is important to consider whether the structures in memory that carry vulnerability are all of the same kind. Whereas the original proponents of behaviour therapy argued that behaviour is mainly under the control of associations that are not consciously accessible, cognitive therapists have tended to argue that the memory structures controlling behaviour are explicit and knowable. Work in social, cognitive, and neuropsychology (e.g. Berry & Broadbent, 1984; Nisbett & Wilson, 1977; Poldrack & Packard, 2003; Squire, 2004) has strongly supported the view that knowledge can be stored both in a form that is open to conscious inspection and in a form that is consciously inaccessible but gives rise to products in the form of moods, impulses, and intuitions. There are now several influential multi-level memory theories of psychopathology (e.g. Brewin (1989), Brewin (1996); Power & Dalgleish, 1997; Teasdale & Barnard, 1993), all of which draw attention to the importance of representations of events that exceed the limits of conscious processing and the implications this has for therapeutic intervention.

Other memory theorists (e.g. Brown & Kulik, 1977; Johnson & Multhaup, 1992; Pillemer, 1998) have made a strong case for the existence of parallel representational systems for images and conceptual knowledge. The image-based system is thought to be highly efficient in capturing sensory experience, requiring few if any attentional resources. Image retrieval is an automatic process, triggered by relevant cues. In contrast, the conceptual system requires considerable attentional resources but enables the storage of representations that can be flexibly retrieved and utilised for planning and other forms of complex thought. Recent research confirms early clinical observations (Beck, 1970; Beck, Laude, & Bohnert, 1974) that many disorders are characterised not only by negative thoughts but by distressing, intrusive images (e.g. health anxiety: Wells & Hackmann, 1993; agoraphobia: Day, Holmes, & Hackmann, 2004; and social phobia: Hackmann, Clark, & McManus, 2000). Likewise, negative thoughts frequently accompany the intrusive memories that are characteristic of PTSD (Reynolds & Brewin, 1998). Some theories of posttraumatic stress disorder (Brewin, Dalgleish, & Joseph, 1996; Dalgleish, 2004) have proposed that different representational systems underpin the negative images and negative beliefs, and require different types of intervention.

Despite the fact that they are often considered (and delivered) together under the umbrella of CBT, behaviour and cognitive therapy have traditionally been thought to be based on different underlying principles. In the next sections they are therefore discussed in turn, paying particular attention to the role of memory representations. I then present evidence from social and clinical psychology that is relevant to the existence of multiple representations and the processes that determine which of them will come to mind. Finally, I shall propose and evaluate a retrieval competition account of CBT and discuss how it can provide theoretical integration for a broad range of alternative therapeutic procedures.

Section snippets

Behaviour therapy

According to the associationist perspective, the behaviour of persistently anxious people is guided by rules automatically abstracted from threatening experiences using principles such as contiguity, contingency, and similarity. For the original proponents of behaviour therapy (e.g. Wolpe, 1973) these rules took the form of conditioned associations that drove behaviour independently of conscious beliefs. Individuals were aware of the kind of stimuli that produced emotional reactions, but not of

Previous research on multiple representations and retrieval competition

As we have seen, the idea that representations in memory compete for retrieval, with negatively valenced structures being latent but winning the retrieval competition in the presence of stressful life events or negative mood, is consistent with Beck et al.'s (1979) original diathesis-stress conceptualisation of depression and with the theoretical position of numerous other authors concerned with vulnerability, relapse, and recurrence in emotional disorders. What is being proposed here is simply

Specification and evaluation of a retrieval competition account of CBT

According to a retrieval competition account of CBT, the purpose of therapy is to alter the relative accessibility of memory representations containing positive and negative information, particularly when patients are faced with challenging situations. It is assumed that potentially there are multiple relevant knowledge structures, some dominated by sensory features (e.g. episodic memories, images), some dominated by somatic and motor responses, and some predominantly verbal and conceptual,

Conclusions

Despite the success of CBT there has for some time been uncertainty about the basic principles that underlie it. The very general nature of the scientific questions concerning psychotherapy, the difficulty in accurate measurement of theoretical constructs, and the impossibility of exerting strict experimental control, all militate against designing critical studies that convincingly favour one theoretical explanation over another. In this field, therefore, alternative scientific criteria for

Acknowledgments

I am very grateful to Allison Harvey, Philip Spinhoven, and Mark Williams for comments on earlier drafts of this article.

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