Cognitive-Behavioral Therapy and Social Work Values:A Critical AnalysisA. Antonio González-Prendes, Ph.D.Wayne State [email protected] BriseboisWayne State UniversityJournal of Social Work Values and Ethics, Volume 9, Number 2 (2012)Copyright 2012, White Hat CommunicationsThis text may be freely shared among individuals, but it may not be republished in any medium withoutexpress written consent from the authors and advance notification of White Hat CommunicationsAbstractIncreasing numbers of clinical social workersuse cognitive-behavioral therapy (CBT) in theirpractice. This article analyzes how CBT fits withsocial work values and in particular with socialjustice. We propose that CBT is a good fit with thevalues of the profession and make suggestions forareas of improvement.Keywords: cognitive-behavioral therapy, socialwork values, social justice, social work practice1.IntroductionIn a day when evidence-based practicehas become so important to the social work profession, cognitive-behavioral therapy (CBT) hasbecome one of the most frequently used forms ofpsychotherapeutic intervention. Extensive researchsupports the effectiveness of CBT approaches fora wide range of psychosocial issues (Dobson &Dobson, 2009; Granvold, 2011). It is one of themost widely researched and published models oftherapy, with more than 325 published outcomestudies that validate its efficacy (Butler, Chapman,Forman, & A. Beck, 2006). This empirical validation has made CBT a popular choice for socialwork practitioners seeking evidence-based treatments. For the purpose of this paper we use CBTas a generic term that encompasses theoretical andpractice approaches that emphasize that a person’sthinking is the prime determinant of emotional andbehavioral responses to life events (A. Beck, 1976;Ellis, 1994; Meichenbaum, 1993). Although theremay be subtle differences among the various CBTapproaches, Dobson and Dobson (2009) identifythree basic assumptions that underscore most CBTapproaches: (1) cognitive processes and contentare accessible and can be known; (2) our thoughtsand beliefs mediate the way we process information and consequently affect our emotional andbehavioral responses; and (3) maladaptive cognitions can be intentionally targeted and changed ina more rational and realistic direction, thus relieving symptoms and increasing functionality. In CBTindividuals are seen not as passive entities simplyreacting to environmental cues or past experiences, but rather as human beings with the potentialto actively shape the course of their lives. CBTmethods are particularly popular in the fields ofsubstance abuse and mental health. “Cognitive-behavioral treatment models are among the mostextensively evaluated interventions for alcohol andillicit drug use” (Magill & Ray, 2008, p. 256), andseveral studies have demonstrated the effectiveness of CBT methods with this population (Rose,2004; Van Wormer & Davis, 2008). CBT is alsoJournal of Social Work Values & Ethics, Fall 2012, Vol. 9, No. 2 - page 21

Cognitive-Behavioral Therapy and Social Work Values:recognized as an effective short-term treatmentsuitable for individuals with various mental healthconcerns (Butler et al., 2006; Leishsenring & Leibing, 2003; Pilling et al., 2002).According to the National Association ofSocial Workers (NASW, 2005), clinical socialworkers constitute the largest group of behavioralhealth providers in the United States. Along theselines, NASW (2006) points out that more than60% of mental health treatment is delivered by social workers. Social work involvement in the fieldsof substance abuse and mental health is prevalentand expected to rise. According to projections inthe Occupational Outlook Handbook, 2010–11edition, the Bureau of Labor Statistics (BLS, 2010)indicates that employment for social workersis expected to grow by 16% between 2008 and2018. The greatest increases are projected in areasassociated with clinical social work: medical andpublic health (22%), and mental health and substance abuse (20%). According to BLS (2010), thetotal number of social workers practicing in thesedomains in 2008 was 206,700. Over time, thesocial work profession has shifted from a focus onpsychoanalytic models of practice to more practical approaches (Ronen, 2007).The past three decades have shown thedistinct influence of CBT on social work theoryand practice evident by the steady increase in thenumber of social workers who use CBT as theirpreferred model of practice (Granvold, 2011; Thyer & Meyers, 2011). A study by Strom (as cited inThyer & Meyers) surveyed clinical social workersand found out that 67% used a CBT orientationand 32% used a behavioral orientation. In 2009,Bike, Norcross, and Schatz replicated an earlierstudy by Norcross and colleagues and found thatwhile only 10% of social workers practiced froma cognitive-behavioral perspective in 1987, thatpercentage more than tripled by 2007. Similarly,in a review of 16 major systems of psychotherapyProchaska and Norcross (2010) found that amongsocial workers, clinical and counseling psychologists, and counselors, cognitive-behavioral orientations comprised the second-largest approach, justbehind integrative models. When they examinedthe social work profession in particular, Prochaskaand Norcross found that 30% of social workersin the United States practice from a behavioral orcognitive orientation. In another survey of licensedclinical social workers across 34 states, Pignottiand Thyer (2009) asked about interventions usedin practice and found that 43% of respondentsused cognitive-behavioral therapy, 18% indicatedcognitive therapy/restructuring, and 12% usedbehavior modification. Other approaches includedsolution-focused therapy (23%) and psychodynamic therapy (21%). Furthermore, when Prochaskaand Norcross polled a panel of experts to forecastthe future of psychotherapy, the results indicatedthat cognitive therapies were projected to be themost popular—with the more generic approach“cognitive-behavioral therapy” ranked number oneand Aaron Beck’s cognitive therapy ranked number three. Since most cognitive therapists integratebehavioral experiments and interventions in theirwork with clients, the differences between cognitive-behavioral and cognitive therapy are mostlikely a matter of semantics and style rather thandifferences in core philosophies. What these studies indicate is the increasing use of CBT amongsocial workers. Yet, at this point no one has reallyasked this question: How does CBT fit with thevalues of the social work profession and its mission of social justice?“Social work is among the most value-based of all professions” (Reamer, 1995, p. 3)and for good reason. Social workers often holdconsiderable power in their work as they regularlywork with the most vulnerable, powerless, andoppressed populations (Compton, Galaway, &Cournoyer, 2005). The NASW outlines strict regulations and ethical obligations that hold its members accountable for their actions. These standardsencourage clients and the general public to trustand be confident in the integrity of the profession(Beckett & Maynard, 2005). A comprehensivecode of ethical standards and guidelines providesan element of validation to the profession. Randall and Kindiak (2008) suggest that the “ultimateJournal of Social Work Values & Ethics, Fall 2012, Vol. 9, No. 2 - page 22

Cognitive-Behavioral Therapy and Social Work Values:evidence of an occupation achieving professionalstatus is professional self-regulation.” (p. 346).When social workers do not abide by these ethicalprinciples, that self-regulation is undermined. Forthis reason, the importance of ethical practice insocial work is clearly essential. Values and ethics have been integral to the profession since itsinception and are critical in shaping social work’sfundamental aims and mission (Reamer, 1995).Ethical principles must be implicit in the practiceof social work. As Sheafor and Horejsi (2006)suggest, “practice principles should reflect a combination of values and knowledge that underlay allpractice activities” (p. 81).Rooted in the preceding discussion, thepurpose of this article is to analyze critically thecompatibility of CBT and social work values. Thisanalysis we believe is long overdue. In this articlewe specifically evaluate how CBT fits with socialwork values outlined in the NASW Code of Ethics(1996), such as valuing the importance of humanrelationships, respecting the dignity and worth ofindividuals, exhibiting competence in practice, andfocusing on social justice. While our discussionfocuses on the micro-practice approach of CBT,we will also address the role of CBT within theconcept of the social environment and its fit withsocial justice.2.MethodologyTo explore available material that wouldallows us to evaluate the compatibility of CBT withsocial work values, we conducted an extensive review of the literature. For this purpose we conducted searches in the databases Social Work Abstracts(EBSCO), PsycINFO, PubMed, Proquest Library,Wilson Select, and Google Scholar. For the searcheswe used keywords: cognitive-behavioral therapy,cognitive therapy, rational-emotive behavior therapy, clinical social work, social work practice, socialproblems, social work values, social justice, worthof the person, importance of human relationships,and competence. In addition we also reviewed theliterature on the effectiveness of CBT with variousdisorders as well as with various populations.3.CBT and the Importance ofHuman RelationshipsNASW (1996) suggests that an appreciation and respect for the value of the importance ofhuman relationships compels social workers to engage their clients as partners in the helping process.From the early evolution of cognitive-behavioraltherapy (A. Beck, 1976; Ellis, 1962, 1994), the nature of the therapeutic relationship has been definedas a collaborative endeavor between the client andthe social worker, one that underscores not only theimportance of that collaborative relationship butalso the importance of the active role of the clientin that process. This collaboration is defined by theclient’s right to self-determination and his or herability to make choices relative to the treatmentprocess (A. Beck, Shaw, Rush, & Emery, 1979; J.Beck, 1995). This collaboration is also underscoredby a focus on clients’ strengths and client empowerment. Both of these concepts, strength and empowerment, are cornerstones of social work practice (Ashford, Le Croy, & Lortie, 2006; Cormier,Nurius, and Osborn, 2009; Van Wormer & Davis,2008; Zastrow and Kirst-Ashman, 2007). As VanWormer and Davis assert, choice is a key aspectof a strength-based approach, and the justice-conscious social worker must ensure that clients areactively involved in making choices relative to thegoals, contexts, and methods of treatment. In CBTthe strength and empowerment perspective is embodied in the concept of “collaborative empiricism”(J. Beck, 1995), whereby clients and social workerswork in tandem to uncover evidence that will helpclients to assess the validity and functionality ofmaladaptive cognitions and to develop healthierand more rational, realistic perspectives of self, theworld, and others.According to Bordin (1994), “a therapeuticalliance grows out of the experience of associationin a shared activity” (p. 16). In CBT the collaboration between the client and social worker reinforces the importance of human relationships andis continually reinforced in all phases of treatment.Therefore in CBT, clients decide what problemsto address and what goals to pursue. FurthermoreJournal of Social Work Values & Ethics, Fall 2012, Vol. 9, No. 2 - page 23

Cognitive-Behavioral Therapy and Social Work Values:in CBT, this client-centered focus is deemed to beessential for therapy to be successful (Gilbert &Leahy, 2007; Hardy, Cahill, & Barkham, 2007).Clients’ choices and contributions extend to theformulation of the therapeutic agenda for eachindividual session (see J. Beck, 1995) as well asthe formulation of homework assignments andbehavioral experiments that allow clients to testout new behaviors and hypotheses in their naturalenvironments.In the CBT model clients are seen as possessing the abilities and strengths to become activeagents in their own change process. Accordingto J. Beck, a key principle of CBT is to empowerclients to “become their own therapist” (p. 7) andthus learn to problem-solve independent of thetherapist. CBT is an empowering approach (Dobson & Dobson, 2009; Hays, 1995). Client empowerment in CBT takes place in various forms, fromsocializing the client to the cognitive-behavioralmodel; to sharing information about the nature ofthe problem that afflicts the client; to providing adetailed rationale behind proposed interventions.Having that knowledge allows clients to makechoices about the context and course of treatment.Empowerment is rooted in the idea of helping clients acquire knowledge and skills to increase theirsense of self-efficacy and power, both personaland interpersonal, in order to take action that willimprove the conditions of their lives (Cormier etal., 2009; Gutierrez, 2001). In CBT, client empowerment is also underscored by these points:(1) Recognition of the expertise that clients haveabout themselves is important. Although the socialworker may have expertise about cognitive-behavioral methods and other change strategies, clientsare the ultimate experts on themselves, and as suchtheir input and participation are actively soughtout. (2) The notion that clients can change theirthoughts and beliefs and in doing so can engenderhealthier emotional and behavioral responses tolife situations has value. Clients are not deemedto be merely reacting to environmental cues or asslaves to their past. Rather, they are seen as havingthe strengths and abilities to rewrite the script ofmaladaptive or irrational messages into more realistic, rational, and balanced perspectives. (3) Thefocus placed on helping clients develop cognitiveand behavioral skills allows clients eventually toapply those skills to various life events independent of the social worker.Traditionally, a criticism of CBT approaches has been that CBT practitioners tend to focusmore on the practical and technical interventionsof therapy and not on the therapeutic relationship.Although it is true that in CBT models the primarymeans of emotional and behavioral change is thechange in cognition, this does not imply a lack ofappreciation for the value of the therapeutic relationship. In the more recent past there has been amore concerted effort to illuminate the value andimportance of positive client/therapist relationship in CBT (J. Beck, 1995; Leahy, 2006). Trueto the premise that practice should be grounded inresearch, CBT recognizes the numerous studiesthat have underscored the importance of empathyand a caring therapeutic relationship in successfultherapy (e.g., Berg, Raminani, Greer, Harwood, &Safren, 2008; Green & Christensen, 2006). Studies on CBT demonstrate that therapists practicingfrom this perspective work to maintain good relationships with their clients (Llewelyn & Hume,1979; Murphy, Cramer, & Lillie, 1984) and thatthey provide encouragement, reassurance, praise,and empathy (Brunick & Schroeder, 1979). According to Keijsers, Schaap, & Hoogduin (2000),“The therapeutic relationship in CBT is characterized by an active, directive stance by the therapist,high levels of emotional support, high levels ofempathy and unconditional positive regard” (p.268). The emotional experiences that result fromthis relationship can be integral to client progressand lead to changes in cognition and client insight(Hardy et al., 2007).4.CBT and Dignity and Worthof the PersonRespect for the inherent dignity and worthof the person implies that social workers treat individuals with care and value, and that they promoteJournal of Social Work Values & Ethics, Fall 2012, Vol. 9, No. 2 - page 24

Cognitive-Behavioral Therapy and Social Work Values:socially responsible client self-determination(NASW, 1996). Similarly, respect for the worth ofthe person is a primary tenet of CBT. CBT therapists accept their clients regardless of their faultsor failings and see value in the person no matterwhat the feeling, behavior, or condition (Ellis,2005). In Rational-Emotive Behavior Therapy(REBT), a CBT model, “.therapists fully accepttheir clients no matter how poor their behavior andthey practice and teach tolerance and unconditional positive regard” (Ellis, 1979, p. 3). CBT avoidslabeling people or making value judgments onindividuals; instead it values open-mindedness anddoes not view people as “good” or “bad” (Ellis,Gordon, Neenan, & Palmer, 1997). In fact, judgmental attitudes and stereotypical labels that frameself or others in absolute and general derogatoryterms are seen as maladaptive and irrational. J.Beck (1995) points out that in cognitive therapysuch pejorative labels, placed on the self or others,are considered as cognitive distortions or errors inthinking that need to be corrected. Instead, cognitive therapists are encouraged to focus on andjudge behaviors for their adaptability and functionality, or lack thereof, while working to accept theirclients fully and unconditionally and to conveysuch acceptance openly. A behavior may be judgedaccording to how it affects the individual’s questto attain his or her life’s goals. However, “bad”behaviors do not define an individual as a “badperson” any more than “good” behaviors defineindividuals as “good persons.” CBT therapists actively teach their clients to accept themselves fullyand unconditionally, regardless of their failings,mistakes, or fallibilities and independent of theapproval or respect that they may or may not getfrom others (Dryden, 1990). CBT views the estimation of self-worth as exceptionally important inrepairing client functioning (Ellis, 2005) and thusstresses the need for client self-acceptance and thetherapist’s strong persistence in reinforcing it (Ellis, 1985).Additionally, the problem-solving approachof CBT emphasizes client self-determination (i.e.,the client chooses what problems to address andwhat goals to pursue) and self-efficacy by facilitating a process that is based on client perspective ofthose issues that are most critical to healthy functioning (Pantalone, Iwamasa, & Martell, 2010).Even though the CBT-practicing social workermay possess the knowledge and skills of therapeutic strategies that facilitate change in the client,therapy is client-centered. The goal is to pass on tothe client the knowledge and skills (i.e., cognitiveand behavioral) that clients will ultimately use toface and resolve life’s challenges. Given that thefundamental philosophy of CBT (A. Beck, 1976;Ellis, 1962, 1994) embraces the belief that clientshave the strengths and ability to change how theyfeel or act by changing how they think, and thatthe client has an active role in determining thecourse of treatment, we suggest that this approachis congruent with social work’s notion of self-determination. Therefore, by respecting and appreciating the inherent worth of the human being, bypromoting an attitude of unconditional acceptanceof self and others, and by encouraging the development of client self-determination in every stepof the therapeutic relationship, CBT and socialwork go well together in this respect.5.CBT and CompetenceCompetence in social work practice implies that social workers practice within their areasof knowledge and expertise and that they strive toincrease their skills and understanding while contributing to the knowledge base of the profession(NASW, 1996). We suggest that competent practice should be based on two factors: (1) the use ofevidence-supported interventions to address clients’ problems, and (2) the effective and efficientuse of time, not only to fit with today’s demandsof the managed care system but also to help reducethe cost of treatment for those who can least affordit. This becomes more important for social workers, who are the most likely practitioners to delivermental health services to the poor and other underprivileged individuals. CBT by nature is a briefand time-limited approach that promotes researchfor the identification of evidence-based practices.Journal of Social Work Values & Ethics, Fall 2012, Vol. 9, No. 2 - page 25

Cognitive-Behavioral Therapy and Social Work Values:No discussion of CBT is complete withoutrecognizing the vast number of empirical studiesthat support its effectiveness across a broad rangeof personal, interpersonal, and social problems(Butler et al., 2005; Dobson & Dobson, 2009;Granvold, 2011). With the growing demand forsocial workers to rely on the use of evidence-basedand time-efficient interventions, CBT offers avalue-laden approach, rich in research evidenceand empirical validation. Strom-Gottfried (2008)suggests that “competence refers to the belief thatsocial workers must be equipped with the knowledge, skills and values needed for practice” (p. 24).Evidence-based practice must rely on results ofcritically appraised research and determines ifinterventions do more good than harm, and that“emphasizes the ethical obligations of professionals in making decisions” (Gambrill, 2007, p. 74)by involving clients in the decision-making andensuring that they are informed throughout thehelping process.CBT approaches promote professionalcompetence through the pursuit of evidence-basedmodels of treatment and ongoing research to validate its use with various disorders and populations.Treatment formats have been developed to includeindividual, group, couples, and family practice(Dobson & Dobson, 2009; Granvold, 2011). Despite the abundance of research supporting the useof CBT across various problems and populations,some criticism exists. Some have suggested thatthe need still exists to promote further researchand evidence with at-risk populations and particularly with racial and ethnic minorities (Bryant& Harder; Granvold, 2011), while others havefound mixed results regarding the efficacy of somemethods (Carroll & Onken, 2005). Unfortunately,CBT’s popularity and common sense approachmay lead some, who do not possess knowledge,training or expertise in CBT, to falsely believe thatthey can effectively engage in the practice of CBT.Therefore when assessing the empirical literatureon CBT, social workers must be cognizant of thefact that the way such methods are implementedmay be the key to individual success and that thelevel of professional knowledge and training andexpertise with CBT techniques could influencetherapeutic efficacy. On the other hand, the popularity of CBT has given rise to the disseminationof treatment procedures through workshops andcourses that provide social workers with opportunities to raise their level of competence as CBTpractitioners, as well as giving them access totreatment guidelines and manuals (Shafron et al.,2009). In order to disseminate information andpromote competence, organizations such as theBeck Institute in Philadelphia and the Albert EllisInstitute in New York City provide training andcertification. Training is aimed at individuals atvarious levels of CBT expertise and developmentwho wish to acquire or enhance their knowledgeand skills, and, if desired, pursue certification. Theend result is to increase the level of competenceamong CBT practitioners. Through its focus onpromoting research, developing evidence-basedpractices, and providing opportunities for continuing education and development, CBT provides social workers with the opportunities to develop theirlevel of competence as social work practitioners.6.CBT and Social JusticeIn a series of seminal articles describingthe relationship between social justice and socialwork, Wakefield (1988a, 1988b) suggests that“justice,” and specifically what he refers to as“minimal distributive justice,” is the organizingvalue and defining function of social work. NASW(1996) suggests that social justice implies that social workers should ensure that clients have accessto needed information, resources, and services, aswell as equality of opportunities and participationin decision making. Although social justice hastraditionally been linked with macro-level practice such as policy making and social reform, andissues such as poverty, discrimination and economic deprivation, Wakefield (1988a) argues thateconomic goods are not the only goods associatedwith social justice and that clinical social work is anatural part of a justice-oriented profession. Wakefield (1998a) suggests that “minimal distributiveJournal of Social Work Values & Ethics, Fall 2012, Vol. 9, No. 2 - page 26

Cognitive-Behavioral Therapy and Social Work Values:justice” in social work ensures not only that individuals receive at least a minimal level of sociallyproduced goods to allow for effective rationalaction but also that “anyone falling below the social minimum in any of the social primary goodsis brought above that level in as many respects aspossible” (p. 295). Following Wakefield’s argument, one would ask what might be the sociallyproduced good that clinical social workers helptheir clients to obtain. And, more specifically, forthe purpose of our discussion, we would ask howthe practice of cognitive-behavioral therapy mightbe compatible with the notion of social justice andhow it might facilitate access to such socially produced goods.For this part of the discussion we refer toRawls (1999), who defines social primary goodsas goods that a rational person may want to pursuein order to improve the quality of his or her life.Rawls identifies such primary goods as liberty,opportunity, income, wealth, and self-respect.Building on Rawls’ ideas, Wakefield (1988b) argues that a major purpose of clinical social workis to aim at psychological justice, and that a keyfunction of psychological justice is the establishment of self-respect, a social primary good,essential for pursuing a rational course of action,a good that is acquired out of one’s interactionwith one’s social environment. Therefore, clinicalinterventions aimed at promoting self-respect andother psychological goods would be congruentwith a social justice perspective (Swenson, 1998;Wakefield, 1988a, 1988b). Consequently, the pursuit of “distributive justice” can occur at eitherthe macro level of practice, through seeking andadvocating for policy and social reform, or at themicro level, through direct clinical social workpractice. When it comes to the pursuit of justice,the NASW Code of Ethics does not differentiatebetween macro- and micro-practice. Furthermore,it seems logical, as Salas, Sen, and Segal (2010)suggest, that “social work is most effective whenthe false dichotomy between working with individuals and working towards social change is reconciled and when social justice is addressed at alllevels of practice” (p. 95). But how specifically,we might ask, can social workers ascertain thattheir micro-level practice—and more specifically,clinical social work practice from a CBT perspective—meets the social justice mission of socialwork? To answer this we look at Swenson’s (1988)discussion of the contributions of clinical socialwork to a social justice perspective. Swenson identifies various factors of clinical social work thatpromote social justice, factors that include havinga focus on client strengths and empowerment,developing an appreciation for resources and context that define the client’s social reality, planningand advocating for services, and addressing socialaction to change social institutions so that socialjustice becomes available to all. Other authorshave suggested that social justice at the micro levelis served when such practice addresses issues ofpower, privilege, and oppression (Jacobson, 2009;Parker, 2003). We argue that CBT—grounded in anonjudgmental, strength-based, and empoweringphilosophy, and placing its focus on promotingunconditional acceptance and respect of self andothers—is a good fit with the social justice mission of social work. Furthermore, we propose thatCBT promotes equality within the therapeutic relationship, aims to understand the context that hasshaped the client’s reality, and promotes a healthylevel of social interest where it is rational to wantto protect the rights of others and address unfairand unjust treatment (e.g., oppression, discrimination) that diminishes the quality of one’s socialenvironment. A discussion of the focus of CBT onclients’ strengths and clients’ empowerment hasbeen made elsewhere in this article.How does CBT demonstrate an appreciation for the contexts that define clients’ realities?For this we look at the CBT concept of “core beliefs” or “schemas.” These entail the most central,fundamental, and absolute views that an individualhas about the self, about the world-at-large, andabout other people (Dobson & Dobson, 2009;Granvold, 2011; J. Beck, 1995). Core beliefs canbe conceptualized as forming a “filter” throughwhich a person looks at life, affecting the way newJournal of Social Work Values & Ethics, Fall 2012, Vol. 9, No. 2 - page 27

Cognitive-Behavioral Therapy and Social Work Values:information is processed and assimilated, how reality is interpreted, and how one defines his or her selfand world views. According to J. Beck, core beliefsbegin to develop in childhood out of the early context of the child’s life. In other words, out of the early experiences with significant others (e.g., parents,caretakers, teachers) and the social environment atlarge, the child begins to formulate and internalizefundamental views about the self, others, and theworld. In this manner individuals who from an earlyage have been subjected to systematic abuse, emotional and physical neglect, degradation, etc., maybe at risk of internalizing negative core beliefs aboutthe self (e.g., “I am not good enough”; “I am unlovable”; “I am defective”), about the world (e.g., “Theworld is a dangerous pla

social work is clearly essential. Values and eth-ics have been integral to the profession since its inception and are critical in shaping social work's fundamental aims and mission (Reamer, 1995). Ethical principles must be implicit in the practice of social work. As Sheafor and Horejsi (2006) suggest, "practice principles should reflect a com-