A Comparison of CBT with Transactional Analysis

ESSAY ASSIGNMENT 1
The counseling model that I have chosen to compare with CBT is Transactional Analysis or TA. I have chosen TA because I have found it to be a helpful model when working with clients; I use elements of TA teaching regularly in my counseling practice. I particularly like the teaching on ego states and have found this useful not only in enabling me to understand my clients but also to enable me to help clients understand themselves and their relationship’s so that they have the tools to identify more helpful options in dealing with people, problems and situations in their lives. More recently I have been interested in cognitive behavioral therapy as a way of working with clients, there is evidence backed by research that CBT is an effective treatment for people suffering from common mental health problems such as anxiety disorders, panic, phobias, post-traumatic stress disorder, depression, bulimia and obsessive compulsive disorder. I will now go on to describe the key concepts of TA and then the key concepts of CBT and how these contrasts with each other. Key concepts TA:
1) Ego states and transactions
TA teaches that communication both internally and externally come from different ego states and that we rapidly move between these ego states according to the context and the environment. There are 3 ego states, parent, adult and child. The parent ego state contains the behaviors, thoughts and feelings copied or interjected from parent figures primarily encountered in the first 5 years of life. The parent ego state can be subdivided into the nurturing parent and the critical parent both of which can have positive or negative characteristics. The message of the parent ego state is ‘I’m ok, you’re not ok’. The adult ego state emerges when the child is around 10 months old and acts like a data processor testing out information from the parent and child state input and making its own internal truth. The adult ego state is value free and feelings free being calm, thoughtful and accepting of self and others. We go into this state by choice, choosing to move toward adult if we find ourselves in the parent or child state inappropriately. The message of the adult is I’m ok you’re ok. The child ego state contains the archaic behaviors, thoughts and feelings replayed from childhood. The assumptions made from the parental message are I’m weak your strong, I’m not ok, you’re ok. If the child receives constant negative strokes the child will learn a lot of performance behaviors in order to get positive strokes and the adapted child develops. However the more positive strokes the child is given the less the child will stifle his own instincts, this being the natural child state. The child ego state can be subdivided into the natural or free child and the adapted child both of which can have negative or positive characteristics. The use of the ego state model is used to analyze sequences of transactions involving a stimulus and a response of one person’s ego state to another person’s ego state. Transactions are described as being complimentary or crossed depending on whether the ego state that is addressed responds or another ego state responds. An ulterior transaction is where there is a transaction that carries a covert message; TA describes games played in relationships which involve ulterior transactions. 2) Strokes:
TA states that people need strokes to survive, a stroke being a unit of recognition and that every transaction whether verbal or nonverbal, positive or negative is an unavoidable exchange of strokes. Stroke hunger occurs when positive strokes are not exchanged freely, this results in stroke seeking behavior. Negative strokes are sought when stroke hungry because any kind of stroke is better than no stroke at all. TA teaches that strokes reinforce behavior. One of the goals of TA is to enable clients to relate to others in an aware, spontaneous, loving game- free way and to enable a free exchange of strokes without ulterior transactions. 3) I’m ok you’re ok:
The TA life positions ‘I’m ok you’re ok’ and that people are born with an inherent tendency for health and healing. 4) Life scripts:
These are described as the unconscious life plans we make in childhood as we interpret our early experiences. Most of our script is made by age 7 and we go on to live out our scripts unaware, setting up our lives towards decisions made as children. In TA ‘redefining’ is said to occur when we distort our perception of reality to fit the script and ‘discounting’ occurs when we ignore any aspect of a situation that would contradict our script. This is because in our child ego state we see anything contrary to our script as a threat to getting our needs met or our survival. The ‘drama triangle’ in TA describes how our script is built by the roles we play in relationships. The 3 basic game roles being persecutor, victim or rescuer are described; people in any of these 3 unhealthy life positions unconsciously seek others to take a complimentary role so that psychological games can be played. The particular manor these roles are performed are described as the building blocks of the script, TA teaches that by giving up these roles will facilitate the abandonment of the script. ‘Injunctions’ in TA are described as mainly preverbal negative restrictive script messages which were interjected as young children from the parents child ego state and are the building blocks of the script. Later messages in child development are called ‘counter injunctions’, these are the parent messages to the child’s parent ego state and consist of commands of what to do and what not to do and definitions about people and the world; they may contradict the injunctions or reinforce them. ‘Drivers’ are described as script driven behaviors, individuals being driven by one or more of these drivers. The drivers are: please others, be perfect, be strong, try hard and hurry up. The child believes he can stay ok as long as he obeys the driver. ‘Rackets’ are described as a set of script behavior’s that the individual uses to manipulate the environment unconsciously and is set up in order to feel a racket feeling, the outcome of the behavior is to justify the feeling. Racket feelings are described as being unauthentic feelings and may be a cover up for real feelings. Acting out scripts and playing games are described as having ‘pay offs’ because the strokes received causes the individual to persist in their behavior thus reinforcing their scripts. Understanding our life scripts is considered an important concept in TA because it enables the client to understand their behavior. TA teaches that these life scripts the lifelong behavior patterns built on habitual games can be re-decide. TA involves exploring why the client wrote their particular life script and helps enable the client to decide how they might like to re-write them. Re-decision can be helped by the therapist’s voice in the client’s head which helps the client go against the injunctions of the parent. TA is contractual in its approach, agreements being negotiated on how the client might like to change behavior patterns and a contract made to this affect putting in place goals and how achievement of goals can be measured. Homework may be given in the form of behavioral assignments. At the earliest opportunity clients are invited to close ‘escape hatches’ these being the script decisions they made as a child to the injunctions received from the parents. Closing of the escape hatches is seen as an important part of the work in TA, it involves the client’s adult refuting the scripts of the child. TA requires a supportive and nurturing relationship so that clients can take greater responsibility for their lives; the language of TA is easy to understand and enables the client with the support and encouragement of their therapist to play an active role in their own therapy. Cognitive behavioral therapy was initially developed in the early 1960s by Dr Aaron Beck. His theory is that during cognitive development incorrect processing and interpreting information are learnt. Influences on the practices of CBT include Rogers, Ellis and behavioral therapists. The cognitive approach makes the assumption that we have cognitions that can cause us problems, these cognitions are looked at during therapy and are the primary target for change in order to work on the client’s cognitive, emotional and behavioral difficulties. CBT teaches that memories of our experience are stored and configured into structures called ‘schemas’. Schemas are formed early in life from personal experiences and from identification with significant others and contain the personal meaning of an event from which fundamental beliefs and assumptions are made. These ‘schemas’ serve as a filter for ongoing experiences. Schemas can be adaptive or maladaptive. Cognitive distortions occur when inappropriate schemas are learnt as a result of negative experiences in childhood and are built upon by further negative experiences that occur throughout our lives. When these inappropriate schemas are activated or when more adapted schemas are inhibited this will cause problems in the individual. Cognitive distortions affect the individual by causing the individual to draw negative conclusions about an event without the supporting evidence. CBT teaches that due to positive experiences received with the resulting positive beliefs our dysfunctional schemas may become conditional. For example a person who has received harsh criticism as a child may develop the dysfunctional schema of being and feeling flawed, however other memories that conflict with this belief may be present the individual not thinking themselves flawed when they are complimented so that a conditional belief occurs if others approve of me I am okay but if others do not approve or voice disapproval then I am flawed. This framework of functional core beliefs and conditional beliefs becomes supported by certain protective behaviors that are employed to protect ourselves from activating the dysfunctional core beliefs and the resulting negative emotions. Protective behaviors for the client that thinks he is flawed might be, avoidance, perfectionism, approval seeking etc. The protective behavior however does not dispute the dysfunctional belief and it may end up reinforcing it. Beck describes automatic negative thoughts which may be thoughts a person has about themselves, the world and the future and that these automatic thoughts are situated in the pre-conscious and arise from the cognitive distortions and the deeper dysfunctional schema content. If left unchecked the automatic negative thoughts will cause the dysfunctional schema and the conditional belief to be strengthened. The protective behavior is reinforced and a downward spiral occurs. CBT focuses on working to change the automatic thoughts by disputing them and recording the new thought so that a conflicting memory is added and so eventually change happens in the dysfunctional schema. CBT by focusing on cognitive processes and how this relates to the way individuals behave aims to change patterns of thinking or behavior that are behind peoples difficulties and so change the way they feel. The philosophy of CBT is that emotions and behavior are determined by our thinking, emotional problems being a result of negative and unrealistic thinking, but by changing the way we think and by developing more positive rational thoughts our emotional problems can be reduced. The client and therapist work together on this so as to develop understanding on what is going on and to develop strategies on how to tackle unhelpful thoughts and behaviors. At the beginning of therapy the client is helped to understand how negative thoughts in relation to the problem leads to emotional and behavioral problems. Psychometric tests such as the PHQ-9 for depression or the GAD-7 are used early in therapy to determine the severity of the disorder, to identify the response to treatment and they are also helpful in discovering cognitions and behaviors that may be perpetuating the client’s problems. The individual aspects of the clients presenting problem are developed with the client into a case formulation. This case formulation forms part of the therapeutic process in CBT enabling the counselor and the client to understand what is causing and maintaining the clients problems and from this develop the therapeutic treatment plan together to help the client reach their defined goals. Although CBT is highly structured the therapeutic alliance needs to be flexible so as to enable the development of new interventions as required, these being made in collaboration with the client following constant evaluation of the therapy. The aims and scientific nature of the case formulation are discussed in the book Assessment and Case formulation in Cognitive Behavioral therapy 2008 ‘Cognitive behavioral theory is used to make explanatory inferences about what is causing and maintaining the client’s problems and to inform the strategies needed to help the client reach their therapeutic goals. The resulting picture contributes to the emergence of contextually appropriate interventions; these feedback on the formulation in constituting hypotheses to test its collaboratively developed appropriateness, usefulness and meaningfulness for the client’ [ref1] Clients are taught to become aware of their thoughts and feelings and to recognize when negative thoughts are triggered. When the client has become more aware of unhelpful negative thoughts the counselor will then help the client understand how these lead to the client’s specified emotional and behavioral problems. Helping the client challenge the evidence or disputing the logic of a thought or belief in order to change it is the next step in the counseling process. Homework may be given between sessions and may consist of the client keeping a diary of incidents that provoke negative feelings so that the thoughts surrounding the incident can be looked at in session and the client helped to reality test the distorted automatic thoughts.. With the understanding that it is their faulty beliefs that are the cause of their problems the client becomes motivated for change and a method of treatment is developed with the counselor, the individual as part of this process being encouraged to substitute more realistic interpretations and so alter the faulty beliefs and assumptions that have caused them to distort events. CBT is a collaborative approach underpinned by the use of contracts; tasks to be undertaken being negotiated and goals then set that will facilitate therapeutic change. The therapist acts as a facilitator throughout this process so their clients develop the skills to become their own therapist. Homework assignments continue throughout therapy and might now include behavioral interventions to support the cognitive change and so bring about behavioral change. CBT counseling sessions are structured and what is done during the week in way of homework tasks is also structured. The BABCP website describes key factors that influence the effective delivery of CBT. It describes a trusting safe therapeutic alliance to be essential but not sufficient for CBT. During the process of counseling with CBT with the therapeutic alliance in place the client is enabled to develop empathy toward self this promoting a greater willingness to engage in the therapeutic process. The book Assessment and case formulation also describes the importance of therapists creating warmth and empathy in CBT, this is seen to provide a safe environment for the client to recognize their emotions and behavior patterns as well as helping clients change their unhelpful behavior patterns. The book also mentions recent research from neuroscience that suggests that an empathic therapeutic relationship can have a direct impact on the brain; the implications are described that the CBT therapist can enable new learning by creating an empathic environment in the therapeutic process. CBT has a strong educational process, this teaching element of the therapeutic relationship empowers the client giving them the tools to evaluate and modify their thinking and behavior. Goal setting is an integral part of CBT, the problems the client wants to work on are identified early in the process and the therapist and client set the goals and session agendas together. CBT being a collaborative approach is also based on mutual respect, there is a shared responsibility in the CBT relationship; the therapist and client examine the client’s beliefs and behavior working together to identify cognitive error as well as working with the client to identify and try out more realistic thoughts including trying out behavioral experiments and adjusting the treatment plan with the client in response to this. CBT is also an active approach the client taking an active role throughout as well as working between sessions on homework tasks agreed with the counselor. Looking at how CBT and TA contrast with each other I have become aware of the similarities particularly that both models are based on the idea that our thoughts and beliefs underpin our feelings and our behaviors and that it is our thinking that determines how we respond in an event. Also key to both models is the philosophy that by learning to identify our thoughts in a particular situation enables not only the understanding of our emotions and behavior but also enables us to change our beliefs and thinking as well as changing how we feel and how we behave. ‘The techniques of the cognitive behavioral therapies correspond closely to what is known in transactional analysis as de-contamination’ [ref2] Other similarities are that both CBT and TA involve helping the client understand the theory so that they are empowered to become their own therapist, the working alliance in both models being a collaborative alliance. Also in both models is the philosophy that people can decide their own destiny and change their decisions. CBT teaches that the schemas formed in response to early experience can be restructured, the core belief changed and maladaptive behavior patterns altered. TA involves re-decision of the early decision that is based on the individual’s script and the working out of that script in the individual’s behavior. CBT and TA are also similar in that they are both structured and goal orientated models, there is a specific agenda for each session which is set at the start, goals are set with the client, being solution focused using treatment planning in response to the diagnosis. The differences between CBT and TA involve the psychodynamic aspect of TA, in the TA model a greater consideration is given to the past to help form the historical diagnosis, CBT recognizes the past may have influenced thinking but other than this feels there is little point looking at the past. Also in TA transference reactions are regularly explored as transactions, this becoming part of the therapeutic process, in CBT although transference reactions are addressed as they come up, the thought processes like TA becoming part of the therapeutic process, there is not so much of an emphasis of this as in the TA model. The cathexis school of TA offers reparenting where the therapist acts as replacement parents connecting with the client’s child ego state giving positive strokes and offering permission to the client to replace the unhelpful injunctions they received from their natural parents. CBT also recognizes the influence of an empathic relationship on the therapeutic process enabling new learning although it does not actually call this reparenting as in the TA model. CBT is different from TA in that the CBT method is a more scientific experimental approach as reflected in the therapist’s ongoing evaluation of change during the therapeutic process. Interventions are generated according to hypothesis and on observing the results of these hypotheses interventions are modified. ‘Cognitive behavioral counseling theory asserts that thoughts and beliefs are hypotheses which can be shown to be true by logic or evidence’. [ref3] CBT is time limited and therapy and is usually brief or short term whereas TA tends to be a longer term therapy and rather than being time limited the work is toward the achievement of an agreed therapeutic goal, however having said this TA is not an open ended never ending processes. Homework a central features of CBT and may or may not be used by TA practitioners. In conclusion Transactional analysis being an integrative approach that combines elements of psychoanalytic, humanist and cognitive approaches is very similar to Cognitive behavioral therapy, particularly as described because of the similarities in the cognitive approach. There are also many other similarities where CBT is being delivered in a person centered way which is not so obvious, these being working with clients transference reactions as part of the therapeutic process and the empathic relationship with the client bringing about therapeutic change similar to the reparenting described in CBT. The TA ego state model that I have found so useful in helping clients understand themselves and their relationships could easily be integrated into the CBT way of working by using the TA ego state model to help clients identify their unhelpful thought processes and then work with the client using CBT concepts in a person centered way would I feel draw the best from each models as well as retaining the scientific approach which is fundamental to the effectiveness of CBT.