Understanding cognitive behaviour therapy: A retrieval competition account
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therapeutic techniques such as desensitisation or exposure were based on behaviourist theories that have largely been superseded by more sophisticated approaches to associative learning in animals and humans (Mineka & Zinbarg, 2006).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.
References (134)
Retrieval of propositional information from long-term memory
Cognitive Psychology
(1974)- et al.
Treatment of childhood memories: Theory and practice
Behaviour Research and Therapy
(1999) - et al.
Memory processes in classical conditioning
Neuroscience and Biobehavioral Reviews
(2004) A cognitive neuroscience account of posttraumatic stress disorder and its treatment
Behaviour Research and Therapy
(2001)- et al.
Psychological theories of posttraumatic stress disorder
Clinical Psychology Review
(2003) - et al.
State and trait differences in depressive self-perceptions
Behaviour Research and Therapy
(1992) - et al.
Flashbulb memories
Cognition
(1977) A cognitive approach to panic
Behaviour Research and Therapy
(1986)- et al.
A cognitive model of posttraumatic stress disorder
Behaviour Research and Therapy
(2000) - et al.
Feared identity and obsessive-compulsive disorder
Behaviour Research and Therapy
(2005)
Coordination of multiple memory systems
Neurobiology of Learning and Memory
Recurrent images and early memories in social phobia
Behaviour Research and Therapy
Acceptance and commitment therapy: Model, processes and outcomes
Behaviour Research and Therapy
Reinstatement of fear responses in human aversive conditioning
Behaviour Research and Therapy
The enigma of organization and distinctiveness
Journal of Memory and Language
An analysis of independence and interactions of brain substrates that subserve multiple attributes, memory systems, and underlying processes
Neurobiology of Learning and Memory
The roles of two levels of cognitions in the development, maintenance, and treatment of depression
Clinical Psychology Review
Treatment of recurrent major depression with attention training
Cognitive and Behavioral Practice
Competition among multiple memory systems: Converging evidence from animal and human brain studies
Neuropsychologia
Remembering can cause forgetting—retrieval dynamics in long-term-memory
Journal of Experimental Psychology: Learning Memory and Cognition
The relational self: An interpersonal social-cognitive theory
Psychological Review
Similarity and inhibition in long-term memory: Evidence for a two-factor theory
Journal of Experimental Psychology: Learning Memory and Cognition
Human memory: Theory and practice
On second thought—where the action is in cognitive therapy for depression
Cognitive Therapy and Research
Situated simulation in the human conceptual system
Language and Cognitive Processes
Role of fantasies in psychotherapy and psychopathology
Journal of Nervous and Mental Disease
Anxiety disorders and phobias: A cognitive perspective
Ideational components of anxiety neurosis
Archives of General Psychiatry
Cognitive therapy of depression
Unlinking negative cognition and symptoms of depression: Evidence of a specific treatment effect for cognitive therapy
Journal of Consulting and Clinical Psychology
On the relationship between task-performance and associated verbalisable knowledge
Quarterly Journal of Experimental Psychology Section A-Human Experimental Psychology
Experiences of depression: Theoretical, clinical, and research perspectives
Worry: A cognitive phenomenon intimately linked to affective, physiological, and interpersonal behavioral processes
Cognitive Therapy and Research
Cognitive change processes in psychotherapy
Psychological Review
Theoretical foundations of cognitive-behavior therapy for anxiety and depression
Annual Review of Psychology
A dual representation theory of posttraumatic stress disorder
Psychological Review
Intrusive memories in depression
Psychological Medicine
Autobiographical memory processes and the course of depression
Journal of Abnormal Psychology
Self-esteem and depression. 1. Measurement issues and prediction of onset
Social Psychiatry and Psychiatric Epidemiology
Self-discrepancies and affect: Incorporating the role of feared selves
Personality and Social Psychology Bulletin
Scientific foundations of cognitive theory and therapy of depression
The construction of autobiographical memories in the self-memory system
Psychological Review
Cognitive approaches to posttraumatic stress disorder: The evolution of multirepresentational theorizing
Psychological Bulletin
Cited by (272)
“Now there are fewer of me". A qualitative study of the impact of psychoeducative groups for complex dissociative disorder
2024, European Journal of Trauma and DissociationThe effectiveness of two novel approaches to prevent intrusions: A pilot study comparing Tetris_dualtask and imagery rescripting to control
2024, Journal of Behavior Therapy and Experimental PsychiatryA single case series of imagery rescripting of intrusive autobiographical memories in depression
2023, Journal of Behavior Therapy and Experimental PsychiatryEffects of imagery rescripting and imaginal exposure on voluntary memory
2023, Behaviour Research and Therapy