Many people don't know that cognitive behavioural therapy (CBT) is not ONE thing. It is an umbrella term that covers lots of different specific cognitive behavioural-based approaches. So what does cognitive behavioural therapy actually mean? All cognitive behavioural therapy is based on the overarching cognitive behavioural model proposed by Aaron Beck[1]. The premise of this model is that all of our experiences can be deconstructed into four key component parts: our thoughts, our emotions, our physical sensations and our behavioural (overt and observable as well as covert and cognitive/attentional). These components all interact with each other, influencing a particular experience.
For example, someone who is experiencing depression may have feelings of sadness, of guilt and perhaps irritability. In a given situation, they may experience thoughts congruent with these feelings “I’m useless”, “why does no one understand me” and so on. The more of these thoughts arising, the lower the person feels. The lower they feel, the more these thoughts become present and believable. Adding to this cycle is the physical experience. Often when people are depressed, they might find their concentration is worse, they may feel fatigued, and their body might feel heavy. It is intuitive to see how these physical feelings interact with both emotional experience and the thought stream and vice versa. Then we have the behavioural component. Faced with all of this heavy internal experience, it is understandable that someone may withdraw. How they may feel the need to ruminate on these scary, unpleasant thoughts and perhaps due to their reduced tolerance, end up snapping at others. And so we have the vicious cycle.
Importantly, when Beck proposed the CBT model of depression[1] (the first iteration of cognitive behavioural therapy was developed specifically for depression and has since been expanded and applied to other presentations), he did not posit that “faulty thinking” caused depression. Instead, the onset of depression should be understood as separate to the maintenance of it. This was revolutionarily for the time, with historical modes of psychotherapy very much fixated on the role of the past, while Beck’s model of CBT positioned the onset as of less significance than the maintenance. This was an aspect of CBT that really endeared me to it. The power of the present.
This “maintenance cycle” of the cognitive behavioural model is a key element that applies transdiagnositically across cognitive behavioural therapy developed for varying presentations. Similar across all CBT models is the identification of the role of these core interacting factors, although some models of CBT focus on three key factors rather than four. For example, in David Clark’s model of panic disorder[2], the maintenance cycle is focused on the physical experience of panic, the catastrophic misinterpretations (thinking) and the safety and avoidance behaviours. Emotions and physical sensations are not delineated from each other. Depending on the presentation, the CBT formulations can vary quite significantly with models of generalised anxiety disorder as developed by Hirsh[3] looking very different from Clark & Well’s model of social phobia,[4] for example (see illustration).
With such fundamental differences between cognitive behavioural approaches across axis I mental health conditions, it stands to reason that the development of CBT for specific health conditions also have substantial variation. In my job, I’ve had many people with IBS say to me “I’ve had CBT before and it didn’t make much of a difference to my gut”. This does not surprise me. Because in each case, the person has had CBT for anxiety or depression or a mixture thereof. It has never been CBT for IBS.
There is a reason that CBT for anxiety or depression doesn’t necessarily change gut symptoms and that is because the target of the therapy is the mood, not the gut symptoms or gut related thoughts and behaviours. During my PhD, I published two papers on this topic. One was a systematic review[5] that identified the key mechanisms of change in psychological therapy for IBS were IBS specific factors, including IBS related thoughts, IBS related anxiety and IBS related behaviours. I followed this study up with my own mediation analysis[6] looking at the sequence of change of these such factors in order for symptom severity to be reduced and quality of life to be improved. This paper was really interesting because it showed that in order for symptom severity to be improved, IBS-related behaviours and IBS-related thoughts needed to change and that these changes pre-empted change in anxiety. I.e. CBT didn’t primarily reduce anxiety, which then enabled change in the way people thought about their symptoms or reacted to their symptoms; it was the other way around. This highlights that the target of CBT for IBS is not general anxiety or mood. The therapy must be designed to target change in IBS specific processes to improve symptoms.
In failing to be tailored to IBS, some necessary components are missed from therapy. These components include:
Comprehensive information about the gut-brain connection and what physically underpins, IBS symptoms.
Specific pattern monitoring in the experience of IBS in order to be able to observe and build understanding of how IBS works, whilst counteracting unhelpful associations that may have been long standing (e.g. fears around food groups)
Bowel symptom related techniques such as anal sphincter muscle exercises if relevant
Increase in tolerance of bowel sensations
Exploration and evaluation of unhelpful bowel related assumptions
One thing that repeatedly strikes me when I work with people who have IBS, is the power of the initial sessions in informing understanding about their condition. In most cases, there has been a significant gap in this understanding (through no fault of their own I hasten to add). Filling this gap has consequently given people much more of a sense of control over their symptoms and reduced a degree of fear. In the Assessing Cognitive Therapy in Irritable Bowel Trial (ACTIB)[7], a repeated theme of feedback from participants was the sentiment that they wished they had been given this information much sooner.
If you are someone who has IBS or know someone who does, you may like to check out a previous post on what CBT for IBS involves. You may also like to enquire about our CBT for IBS services which include an online 8-week therapy group held 3-4 times a year, CBT for IBS therapy or guided self help, using the evidence-based programme from the ACTIB trial.
[1] Beck, A. T. (Ed.). (1979). Cognitive therapy of depression. Guilford press. [2] Clark, D. M. (1997). Panic disorder and social phobia. [3] Hirsch, C. R., Beale, S., Grey, N., & Liness, S. (2019). Approaching cognitive behavior therapy for generalized anxiety disorder from a cognitive process perspective. Frontiers in psychiatry, 796. [4] Clark, D. M. & Wells, A. (1995). A cognitive model of social phobia. In R. Heimberg, M. Liebowitz, D. A . Hope, & F. R. Schneier (Eds.), Social phobia: Diagnosis, assessment and treatment. (pp. 69-93). New York: Guilford Press. [5] Windgassen, S., Moss‐Morris, R., Chilcot, J., Sibelli, A., Goldsmith, K., & Chalder, T. (2017). The journey between brain and gut: A systematic review of psychological mechanisms of treatment effect in irritable bowel syndrome. British Journal of Health Psychology, 22(4), 701-736. [6] Windgassen, S., Moss-Morris, R., Goldsmith, K., & Chalder, T. (2019). Key mechanisms of cognitive behavioural therapy in irritable bowel syndrome: the importance of gastrointestinal related cognitions, behaviours and general anxiety. Journal of Psychosomatic Research, 118, 73-82. [7] Everitt, H. A., Landau, S., O’Reilly, G., Sibelli, A., Hughes, S., Windgassen, S., ... & Moss-Morris, R. (2019). Assessing telephone delivered cognitive–behavioural therapy (CBT) and web-delivered CBT versus treatment as usual in irritable bowel syndrome (ACTIB): a multicentre randomised trial. Gut, 68(9), 1613-1623.