Towards a full-spectrum cognitive behavioral psychology

SONY DSCRichard M Gray & Frank L. Bourke

The authors hold CBT and NLP up for scrutiny and explore the limits and advantages of both treatments

Neuro-linguistic Programming (NLP) is a means of recognizing and replicating patterns in human behaviour and perception, and making those patterns available for skill training, behaviour modification and study. It has created treatments for phobias , trauma, PTSD, anxiety and depression .

Cognitive Behavioral Therapy (CBT) represents the most studied and for many issues the most effective treatment available. Those results are for the most part, however, uneven.  NLP comes to cognitive psychology with a set of enhancements that can increase the efficacy of cognitive interventions by shortening treatment time, increasing sensitivity to individual variations and increasing the utility of cognitive schemata in the treatment of problem behaviors. In short, NLP offers the potential for a full-spectrum cognitive behavioral approach (Liotta, 2012).

CBT: abstract generalizations
Both NLP and CBT focus upon patterns of behavior as sequences of things perceived (internally or externally), and the emotional or cognitive responses that they provoke. In CBT the schema is derived from a synthesis of multiple examples that are formulated into abstract generalizations. Hence, CBT arrives at the generalized pattern or schema of depression from modeling numerous clinical examples. These generalized schemata usually include a perception, an emotional reaction to the perception, the client’s irrational interpretation of the response and/or their reaction, and often, a magnifying loop. These have been described for the well-known symptoms of sadness, withdrawal, lethargy, fatigue and others.

NLP: finding internal representations
In NLP, clinical work finds the specific internal representations that produce the emotional or cognitive response that gives rise to the problem. Hence, a depressed client may be obsessively repeating the pictures of his mother’s recent death and producing the symptoms of diagnostic generalization, depression. The NLP formulation must always contain the internal steps or process by which the client ‘does the problem’. CBT schemata are validated by their ability to describe generalized response patterns where the specific internal representations producing those schemata are unknown. NLP therapeutic operations are validated when changes in the internal sequences of the internal representations constituting the problem result in problem resolution. NLP describes the target behaviour, identifies its structure, and the possible modifications that are indicated for problem resolution. Because, in NLP, every diagnosis is an individual diagnosis, most evaluations of NLP-based clinical interventions are not amenable to the more common methods of scientific evaluation.

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CBT acknowledges more than 10 varieties of depressive schemata and, by describing the specific structure of each individual case, NLP finds innumerably more. In order to study the results of NLP interventions, clients need to be provided with a subjective evaluation of symptom severity that can be assessed statistically across multiple cases in pre- and post-treatment conditions. The general diagnosis might be framed in terms consistent with the American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders (DSM) or the World Health Organisation International Classification of Diseases (ICD) but the target of the treatment is the client’s self-described problem and their clearly defined emotional and behavioral goals (how the patient feels). These kinds of responses can be evaluated using a psychometric rating scale such as that developed by Likert (1932): on a scale of one to ten, how does this feel; on a scale of one to ten, how does this affect your everyday function; on a scale of one to ten, how often do you display behavioral symptom x; on a scale of one to ten, how have your emotional and behavioral goals for treatment been met? With sufficient care for scale development, such a subjective measure could be used by the thousands of NLP-trained therapists to assess the efficacy of their approach; those data could be aggregated across a large sample of case studies to provide a measure of the subjective value of NLP interventions for any broad diagnostic category.

NLP practice, properly executed, never sets the clinical goal on either CBT schemata or diagnostic criteria. The therapist isn’t attempting to help the client get un-depressed but rather to stop obsessing internally on the pictures of their mother’s recent death. Clinical success is found when a change in that internal process results in the alleviation of the problem symptoms.

Identification of schemata
One of the signal accomplishments of CBT is the precise identification of schemata characterizing a large number of specific disorders. Most familiarly it has provided them for anxiety disorders, phobias and OCD. After many years of experimental evaluation, the patterns are well defined and correspond well to clinical experience, yet these interventions are less effective than might be expected. NLP would suggest that although CBT has clearly identified the large-chunk sequences, by not accounting for the small changes in subjective experience that code for meaning and affective impact, it has been unable to take advantage of its own strength, reliable models of behavior.

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NLP comes to this impasse with several offerings: a radically client-centered approach in which every individual’s subjective experience is unique; a means of analyzing and manipulating perceptions (the sub-modality distinctions), that makes the intervention personally meaningful to the patient; sufficient flexibility for the therapist so that multiple interventions may apply to any schematic intervention.

NLP: truly client-centered
NLP offers possible additions to CBT that have strong validations in mainline psychology and neuroscience. The sub-modality distinctions reviewed below have extensive validation in the experimental literature, while their application to therapeutic interventions is comparatively novel (Gray, Wake, Andreas, & Bolsted, 2012). The linguistic distinctions, also noted below, were derived from standard linguistic categories used by Chomsky, Jakobsen and others. While there is significant literature attached to their presence in linguistics, they are novel in their use in therapy. They do, however, represent a significant parallel to the cognitive distortions and irrational beliefs of CBT.

NLP begins with a set of assumptions that operationalize a truly client-centered orientation. Most of these ideas can be traced back to Rogers (1951) and Maslow (1943) as well as Virginia Satir, Milton Erickson and Alfred Korzybski. Several of these presuppositions find a certain correspondence in the assumptions that people generally want to be happy and to behave rationally. Among these presuppositions are:

The meaning of communication is determined by the listener’s understanding. The therapist is responsible for insuring that both he and his client understand each other,

If what you are doing doesn’t work, do something different. NLP assumes a level of flexibility by the therapist that allows for multiple approaches to any problem.

The map is not the territory. This tells us that neither our own nor our client’s understanding of the world is an actual match for the world itself; it is our job to ensure that we have asked enough questions so that the client’s and our own world-views are accurately represented in the two-way process of communication.

Every behavior has a positive intention. This means that behavior has meaning and perhaps survival value from the client’s perspective; however aberrant, perverse or irrational it may be to us, understanding from the client’s perspective is crucial.

Every behavior is meaningful in some context. Once we have understood the original context of the behavior, or how the client finds place for it subjectively, we have a better hope of making therapeutic progress.

There are other presuppositions but in the realm of therapeutic interventions these are the essential core.

NLP: capturing the subtleties of individual experience
An important innovation emerging from NLP’s modelling is the refinement of diagnostic categories to reflect the patient’s internal ordering of the perceptions that give rise to the symptom or problem. This radically client–centered approach represents a further refinement of cognitive behavioral practice. NLP recognizes the broad categorical definitions in the DSM and the ICD but captures, for clinical utilization, the almost infinite subtleties of individual experience that those categories encapsulate. NLP reimagines pathology in terms of client-specific maps, and patterns of affect and behavior that can be changed. A spider phobia, for example, is a specific cognitive representation composed of sights, sounds and feelings that can be modeled and changed by manipulating the structure of those perceptions. The multisensory representation of the phobic stimulus can be changed from eg a huge, three-dimensional spider, with weight and texture, climbing up a person’s arm to a distant, tiny spider, safely contained in a jar.

This kind of perceptual alteration will generally change the feeling component of the schema and with it the phobic response. Further, NLP sees every individual as capable of making new choices in how they understand and deal with the world. Insofar as it is susceptible to cognitive-behavioral intervention, a DSM diagnosis of Severe Depression might be described in NLP practice (as determined from interviews with the patient) as an obsessive internal voice in the same tone and timbre as the client’s long-deceased, overbearing mother. This provides the therapist with the client’s own internal representations which generate and maintain the depression, and can now be altered to alleviate it.

CBT: recasting the schema
For CBT the incorporation of perceptual changes implies the recasting of the schema to include the client’s personal experience. The classical schema for a panic attack, or other anxiety disorder, is: an irrational and disproportionate or catastrophizing interpretation of an otherwise unremarkable event. This description focuses upon the content of the response and the clinician’s interpretation of the response as irrational or disproportionate.

NLP: working with the client’s responses
NLP takes the position that in the client’s world, the interpretation is realistic and is experienced as threatening; her perceptions justify her responses. After all, the response has prevented the worst from happening in the past. NLP now re-codes the schema in terms of the client’s perceptual distortions (known as sub-modalities) that are subject to conscious manipulation by the client. A second difference is in the use of language. Beck (Beck, 1976; Burns, 1980) and Ellis (1962) each identified typical patterns of irrational or distorted language that describe the patient’s response to the initial stimulus. These are often judgments about the content of the responses.

The Meta-model: examining the elements
The NLP meta-model provides specific challenges for language patterns that reflect distorted meanings or perceptions. In contrast to CBT, NLP does not target the rationality of the statement, but its structure.
Rachman  records the example of an Obsessive Compulsive patient who asserts the irrational belief that “Whenever I am responsible things are more likely to go wrong.” (1997, p.796) Or, more expansively, “If I am responsible for ensuring the safety of the house, the probability of a fire occurring is significantly greater than it would be if you were responsible for its safety.” NLP does not challenge the entire statement but examines its elements point by point in order to capture information that is no longer available to consciousness.

“Whenever I am responsible…” is a universal quantifier; it is language that implies no options. It is challenged by asking things like “Every time? Every single time? There has never been a time when you were in charge and terrible things did not happen?” It is also challenged by counter-example: “Perhaps you can think of a time when you were in charge and nothing happened.” Such challenges are often pressed to the point of absurdity.

In full agreement with CBT’s idea of thought-action-fusion there is the cause-effect distortion; the idea that one unrelated thought can and must give rise to a subsequent and often unwanted action. It is challenged by asking the patient how he knows this will happen or how many times he has actually seen this chain of events worked through in the past.

The word ‘things’, is an example of unspecified referential index. Because the referent is unspecified there is no possible test for its truth-value. It is challenged by asking, “What specific things go wrong?” and requiring precise examples.

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The Phrase “… things are more likely to go wrong…” exhibits a lost comparative and is challenged: “More likely than what?” Once again the language is brought back to the client in an effort to clarify the meaning and to engage her undistorted experience of the world.

The meta-model is non-judgmental. It can always be presented gently, as a means for clarifying and further understanding the client’s model of the world. When it is presented so, there is little room for resistance, just gentle, respectful probing that helps the client to expand the borders of their world-map.

Sub-modalities: the dimensions of importance and intensity
According to the classical view of cognitive schemata many anxiety disorders are triggered by an exaggerated sense of the importance of an event or ideation. A religious person exaggerates the implicit blasphemy in a passing thought, a homophobe over-reacts to an appreciation of the male figure, a person afraid of violence exaggerates a passing violent thought. In each such case the evaluation is typically branded by the therapist as illogical, catastrophizing or otherwise in need of correction. NLP, however, looks to the structure of the thought; how its internal representation as a picture, a voice or a feeling might be distorted in such a way as to accord it extraordinary salience. These perceptions are mediated by the sub-modality structure of the perception.

Sub-modalities are the details of sensory experience that code for valence and intensity. They include distance, focus, movement, complexity, intensity, size, speed and position. They operate pre-consciously and with practice can be used by anyone. Their relationship to emotional impact and salience is well documented.

Applying sub-modalities to the patient’s response to the trigger might find that he holds a brightly coloured picture of the anticipated calamity moving across his imagination that is big, close, and brightly lit. The client can be taught to practice making the picture smaller, moving it into the distance, draining the colour from it and giving it a frame. Practice with other less troublesome stimuli can give the patient enhanced confidence in using the intervention.

In the case of a sound stimulus, a patient might report the memory of her mother’s voice intoning the same destructive message over and over, close-by, loudly, with rasping tonality, from a specific locus in space. Working with the patient to modify the structure of the experience, the clinician might discover that turning down the volume, moving the voice to a different point in space, giving it some distance, and providing it with some melody might transform the voice into a loving reminder that she is loved and needs to be careful.

Other interventions : anchors and conditioned responses
Continuing to work with the same schema, it might happen that the simple sub-modality intervention is insufficient and the image, sound or feeling continues to return to its pathogenic form. In this case, NLP provides a series of possible interventions. One of the more familiar ones might involve the use of anchors, conditioned responses to bring to bear some positive affect to the structure of the schema. Other NLP interventions have been created for a wide range of psychological problems.

The Interface between NLP and CBT: promises for the future
CBT and NLP share common roots in the work of Chomsky, Bateson and others. While CBT has followed the tradition of mainline scientific investigation, NLP has proceeded as an intuitive, empirical art. Both disciplines work to create descriptive models of behavior as sequences of perceptions, affective responses and reactions. Despite its strong empirical roots, CBT’s successes, although greater than most therapies, fall far below its potential. NLP provides a set of tools that hold forth the promise of increasing the personal specificity and effectiveness of CBT.

CBT has amassed a considerable number of well-validated models of common pathologies. This library of general patterns provide for the NLP community a jump- start on the creation and testing of effective techniques from its unique client-centered perspective.

In the preceding, we have discussed the interface between NLP and CBT and some of the scientifically validated tools from NLP. We have discussed how insights from NLP might give rise to a full-spectrum, client-centered CBT. This short introduction does not begin to plumb the depths either of NLP or CBT. It has, however, pointed the way to positive practices, with strong scientific support, that may serve to enhance the already formidable record of CBT into a full-spectrum set of clinical tools.

Richard M Gray, Ph.D. is Research Director for the NLP Research and Recognition Project. Formerly Assistant Professor in the School of Criminal Justice, Fairleigh Dickinson University, Teaneck, NJ. Dr. Gray served for more than 20 years in the US Probation Department, Brooklyn, NY. and was the recipient of the 2004 Neuro-Linguistic Programming World Community Award in Education for his work with federal offenders with substance use disorders. He is author or co-author of a number of publications and a member of the Canadian Association of NLP, The NLP Research and Recognition Project, The Institutes for the Advanced Study of Health, and the American Psychological Association.
Dr. Frank Bourke is the Executive Director of the NLP Research and Recognition Project and Coordinator to the NLP Community. He is a Licensed Clinical and Research Psychologist with more than 33 years of professional experience in executive, clinical and research roles including Associate Professor of Community Psychology at the New York School of Psychiatry and Lecturer in Community Mental Health and Psychology for Cornell University Psychology and Education Departments. He founded the Not For Profit Corporation to advance the science of Neuro Linguistic Programming and, after the 2001 9-11 attacks, designed and implemented a rehabilitation plan for 800 World Trade Center building survivors.

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