This is the title of the seminal 2nd Edition of this work, by David F Tolin, published last year by Guilford Press. He sees CBT at its’ core, as focussed on the reciprocal interactions of cognitions, behaviour, emotion and physiology. So that changing any one will impact on the others. This will be very familiar to all CBT therapists, for example if feeling low you could go for a walk (physiology) or alternatively change your thinking from ‘I have too much to do’, to ‘ I can get through it all, if I just pace myself with breaks, doing only one task at a time’. The strategies adopted synchronise with each other. Interestingly he describes his way of doing CBT, which he acknowledges might not be how another expert clinician might conduct CBT. This could be regarded as flexibility but it also may cause problems with regards to fidelity.
For example he advocates, p xi, ‘that we de-emphasise the DSM In favor of a broad set of principles …which we can apply to all our clients, no matter who they are or what problem (s) they have’. But Judith Beck in CBT The Basics and Beyond (2020) states that the first thing she does is a diagnostic evaluation. Throughout her book she describes the treatment of 2 clients one with simply depression and the second with depression and a borderline personality disorder.
Without categorisation both clients would likely have been treated in the same way.
Tolin makes no mention of cognitive content specificity i.e that disorders are distinguished by their different cognitive content. Knowing the disorder(s) likely flags up a particular set of cognitions to be addressed, for example in PTSD those embodied in the Trauma Cognitions Inventory, Scott (2024) Moving On After Trauma 2nd edition. Without this the nascent CBT therapist might ‘zap’ every negative cognition in sight.
Fidelity is more difficult to gauge with Tolin’s approach. He states that clients can be advised of a 50% recovery rate across the anxiety disorders on the basis of randomised controlled trials. Though on average treatment gains were maintained, it is unclear from the rcts what proportion of clients maintained recovery for say 6 months. This is the real-world data of interest to clients.
Clinicians working in routine practice have to be accountable, but this cannot be easily demonstrated if a therapist is doing their own version of CBT. Treatment integrity is a major pressing and unaddressed issue in routine practice. Service providers have shown no inclination to address this, perhaps fearing that to do so might threaten their very existence. Neither Beck or Tolin, address the very different working context of routine practice, where I suspect flexibility has become infidelity.
Dr Mike Scott