We will say more in a later section about CBT-specific models of learning and memory. For the moment, it might be helpful to situate an understanding of reflection as a skill, and reflective practice as an approach to improving professional proficiency, within the broader domains of cognitive and educational psychology where terms such as cognition, cognitive processes, memory, knowledge, learning and performance are explicitly differentiated. Cognition has proved extremely difficult to pin down in both philosophy and cognitive science (Allen, 2017) but might be thought of as “the mental processes involved in acquiring and processing information that are necessary for everyday living” (Magni & Bilotti, 2016, p. 411). Cognitive processes, including memory, problem solving, and reasoning are constituent parts of the concept of cognition. Memory is the faculty of the mind to store and remember information and experience whereas knowledge is the possession of information or of where to locate it, in other words, the sum of what is known. Learning is the process by which knowledge and skills are acquired, organised or modified and performance is the ability to deploy or make use of knowledge in various settings (adapted from Differentiating Between Learning, Knowledge, Performance, Memory & Cognition, 2018). The concept of understanding is seen as more than mere knowledge of facts. Ellerton (2017) describes it as meta-knowledge, that is, knowledge of the relationships between those things that are known, organised into schemas for convenience. The more effectively our knowledge of a domain is organised, the better we can make use of it to solve problems. Knowledge is transformed into understanding through the use of cognitive processes, for example the cognitive skills of being able to analyse, evaluate, justify, synthesise, organise, identify, infer, categorise, and hypothesise.
There is an important relationship between motivation, emotion and willingness to learn. In her article titled “Do not block the way of inquiry”, Haack (2014) cites Charles Sanders Peirce, the 19th Century American philosopher credited with being the father of pragmatism, as stating that the first rule of reason is that “In order to learn you must desire to learn, and in so desiring not be satisfied with what you are already inclined to think” (p. 319). In a similar vein, Ellerton (2017) states that “If we are to value inquiry, we must value doubt, for doubt is the beginning of inquiry” (p. 6). The term “inquiry” is taken to mean something more than behaviour that is customary, conventional or traditional, but a form of self-correcting practice that is by nature reflective (Lipman, 2013). For Ellerton, teaching settings in which knowledge is presented in a way that makes it appear ‘settled and clear’, “imply an absence of doubt, hence an absence of inquiry, hence an absence of opportunities to engage in reflective thinking, and hence an absence of opportunities to improve thinking” (p. 6).
Motivation and emotion are closely linked, and affective states therefore have a strong influence on learning. Tyng et al. (2017) point out that affective states affect diverse areas of cognitive processing such as perception, attention, memory, reasoning, and problem solving, and have a particularly strong influence on attention, where emotion modulates the selectivity of attention as well as motivating action and behaviour. Emotion can be described in terms of valence, intensity, and duration, and the right amount of the right kinds of emotional experience helps both encode memories and assist in the efficient retrieval of information. Emotion not only assists in learning; it may also determine what is learned, sometimes with unforeseen consequences. As Carl Buehner’s widely quoted aphorism neatly puts it, “They may forget what you said — but they will never forget how you made them feel” (Evans, 1971).
Motivation and emotion are closely linked, and affective states therefore have a strong influence on learning. Tyng et al. (2017) point out that affective states affect diverse areas of cognitive processing such as perception, attention, memory, reasoning, and problem solving, and have a particularly strong influence on attention, where emotion modulates the selectivity of attention as well as motivating action and behaviour. Emotion can be described in terms of valence, intensity, and duration, and the right amount of the right kinds of emotional experience helps both encode memories and assist in the efficient retrieval of information. Emotion not only assists in learning; it may also determine what is learned, and sometimes the emotional experience is the learning. As Carl Buehner’s widely quoted aphorism neatly puts it, “They may forget what you said — but they will never forget how you made them feel” (Evans, 1971).
It is likely that emotion is of particular relevance in experiential learning as contrasted with academic learning. Whereas academic learning emphasises “learning about” a subject dispassionately using academic study methods in order to produce greater knowledge and understanding of a field of study, and procedural learning makes use of practice and instruction to develop automated motor and cognitive skills (such as learning to ride a bicycle or learning to read), experiential learning emphasises the importance of learning through reflection on doing. And the kinds of “doing” that are perceived as salient are those that elicit relevant emotions whether that is surprise, shock, horror, sadness, joy or sudden enlightenment. All three forms of study (academic, procedural and experiential) are important in developing professional practitioner competence but experiential learning has been perhaps the least developed to date in CBT, so it is worth reflecting on its origins and development outside of CBT.
The roots of an experiential learning approach are usually cited as being found in the work of the 19th Century American philosopher, psychologist and educationalist John Dewey whose work is both widely quoted (and frequently misquoted, e.g. Lagueux, 2014), who we will discuss in more detail a little later. The modern sense of experiential learning is usually traced to David Kolb (1984), whose experiential learning model is a synthesis of Dewey’s and Lewin’s models of experiential learning and of Piaget’s model of learning and cognitive development, as well as being influenced by the psychologist Jerome Bruner and the radical educationalist Paulo Freire. What is usually described as Kolb’s model of experiential learning is in fact Lewin’s learning model. Lewin emphasised the importance of “here-and-now concrete experience to validate and test abstract concepts” (Kolb, 1984, p. 21, italics in original) and on feedback processes that provide the basis for “a continuous process of goal-directed action and evaluation of the consequences of that action” (ibid, p. 22). The Lewin model thus describes a cyclical pattern from concrete experience to reflective observation, followed by abstract conceptualisation and then active experimentation (Figure 3). As Kolb succinctly puts it, “Immediate concrete experience is the basis for observation and reflection. These observations are assimilated into a ‘theory’ from which new implications for action can be deduced. These implications or hypotheses then serve as guides in acting to create new experiences” (ibid, p. 21).
Kolb (1984) compares Lewin’s model to Dewey’s model of experiential learning in which there is a similar emphasis on a dialectical process that integrates experience and concepts with observations and action such that “the impulse of experience gives ideas their moving force, and ideas give direction to the impulse” (p.22). Kolb also draws on Piaget’s concept of the interplay between processes of assimilation and accommodation as determinants of learning, or intelligent adaptation as Piaget termed it. Kolb concluded that learning is therefore best conceived of in terms of process, rather than outcomes. He stated that there are no fixed and immutable ideas because “no two thoughts are ever the same, since experience always intervenes” (p. 26). Kolb also cites Paulo Freire as drawing a distinction between education as a way of “banking” facts by depositing information in the mind of the learner, and a process by which knowledge emerges through “invention and reinvention, through the restless, impatient, continuing, hopeful inquiry men pursue in the world, with the world, and with each other” (Freire, 1974, cited in Kolb, 1984, p. 27).
Predating the publication of Kolb’s work by some years, the American high school teacher Terry Borton published a book on reflective education called Reach, Touch, Teach (1970) that developed and tested a curriculum for children from under-privileged backgrounds. It was designed to reach children at the level of basic personality, touch them as human beings, and teach them in an organised fashion. Rolfe (2014) subseqeuntly made the model more widely known and points out that Borton’s three-stage model anticipated some of the key features in Kolb’s experiential learning cycle. Rolfe also points out that Borton’s model drew on the then dominant model of cognition that arose from the “cognitive revolution” that usurped behaviourism in the 1960s. Human Information Processing, as it was known, employed the metaphor of computer as an analogy for human cognition and Borton identified three relevant cognitive processes: sensing to bring the person into contact with experience, transforming, by which meaning is made of experience, and acting, which involves an engagement with the world. The three processes were operationalised in terms of three colloquial questions. In Borton’s words:
“What?” for Sensing out the differences between response, actual effect, and intended effect; “So What?” for Transforming that information into immediately relevant patterns of meaning; “Now What?” for deciding on how to Act on the best alternative and reapply it in other situations. This What, So What, Now What sequence became the model on which we built a curriculum designed to make students more explicitly aware of how they function as human beings. (Borton, 1970, cited in Rolfe, 2014, p. 488).
Borton’s (1970) final point about raising awareness of how people function as human beings is of particular relevance to psychotherapy in general and CBT in particular. The goals of psychotherapy are often framed in terms of an espoused intent to alter psychological and behavioural processes in the service of enhancing quality of life and promoting adaptive functioning (American Psychological Association [APA], 2012). Borton’s goals of reaching his pupils at the level of personality, touching their lives, and organising structured teaching interventions, mirror the goals of CBT. CBT seeks to create an interpersonally sensitive yet profound encounter with the person of the client through a structured intervention that helps people to develop the skills and attitude to promote recovery from mental health problems. This structured, reflective process is epitomised in the use of Socratic questioning as a form of guided discovery in CBT. Padesky (1993) describes guided discovery as a method of inquiry that makes use of facilitative process components such as the use of empathy to enhance a sense of safety and of summarising to reduce the load on working memory. Guided discovery is focused both on the content of experience as it is subjectively perceived using “what” style informational questions to describe events, and on its implications. “So what” synthesising questions are employed to explore the meaning and implications of events and reconceptualise them using discursive cognitive reconstruction tasks before planning further “now what” actions.
Mezirow (1997, 2009), who was a contemporary of Borton and Kolb, conceptualised adult learning as a potentially transformative process. Transformative learning is worth examining because it could be conceptualised as a conceptual bridge between experiential learning theories and the potentially transformative power of CBT as an approach to psychotherapy that is based on learning theories. Mezirow’s Transformative Learning theory was derived both from his academic and professional work as an adult education consultant in developing countries with his personal observations of the profound effect on his wife of her return to education to complete her degree as an adult learner. Mezirow defined transformative learning as:
“the process by which we transform problematic frames of reference (mindsets, habits of mind, meaning perspectives) – sets of assumption and expectation – to make them more inclusive, discriminating, open, reflective and emotionally able to change” (2009, p. 92).
Mezirow’s language is explicitly psychological and phenomenonological, stating that a defining condition of being human is to understand the meaning of our experience. As we saw previously, he draws a distinction between uncritically assimilating explanations by authority figures as opposed to developing autonomous thinking based on our own interpretations. Conceptually, Mezirow describes a hierarchical meaning framework; at the most abstract level are frames of reference that define one’s “lifeworld” using Habermas’s concept of lifeworld, which can be understood as:
“the background resources, contexts, and dimensions of social action that enable actors to cooperate on the basis of mutual understanding: shared cultural systems of meaning, institutional orders that stabilize patterns of action, and personality structures acquired in family, church, neighborhood, and school” (Habermas, 1988 cited in Bohman & Rehg, 2017: section 3.1, para 12)”.
Frames of reference are the “structures of assumptions through which we understand our experiences” (Mezirow, 1997, p. 5) and they selectively shape and delimit expectations, perceptions, cognitions and feelings. They function to direct behaviour down certain paths, switching from one mental or behavioural activity to another. They affect the processing of information in that they give rise to confirmatory bias by which ideas that fail to fit our perceptions are rejected. They are “structures of culture and language through which we construe meaning by attributing coherence and significance to our experience” (Mezirow, 2009, p. 9).
Frames of reference encompass habits of mind and points of view. A habit of mind is a broad, abstract, orienting and habitual way of thinking, feeling and acting. Habits of mind are influenced by assumptions that collectively form a set of codes that in turn may be cultural, social, linguistic, educational, economic, political, psychological, religious, aesthetic, and so on. Habits of mind tend to be taken for granted as a veridical representation of the world, rather than acquired opinions. A point of view is more concrete and accessible to feedback from others. It is “the constellation of belief, memory, value judgement, attitude and feeling that shapes a particular interpretation” (Mezirow, 2009, p. 92).
Mezirow (1997) gives the example of ethnocentrism as a habit of mind that predisposes a person to regard people not perceived to be part of one’s own group as in some respect inferior. Ethnocentrism as a habit of mind leads to the complex array of feelings, beliefs, judgements and attitudes we may have regarding specific individuals or groups that have characteristics perceived to be different to our own. In terms of learning, having a positive experience may change one’s point of view regarding a specific person or group, but would not be expected to change the broader and more abstract tendency towards an ethnocentric habit of mind.
Mezirow’s conception of learning tallies closely with Beck’s conceptualisation of the role of schemas in organising the phenomenology of human experience, perhaps because both draw on the developmental work of Piaget. Indeed, Mezirow makes direct reference to Jeffrey Young’s Schema Therapy, which is an adaptation of CBT that focuses on treating personality disorder (Mezirow, 2009). While Beck and Young both focus on psychotherapy as a specific learning environment for overcoming psychopathology, Mezirow’s transformative learning theory draws on more general theories of learning that are not necessarily related to the acquisition, maintenance, or recovery from, mental health problems. He does however acknowledge that while transformative learning and psychotherapy might have much in common at a conceptual and process level, psychotherapy is a form of transformative learning that is likely to generate considerably higher levels of anxiety.
To change a habit of mind or frame of reference, a process of profound learning needs to take place. Mezirow borrows the German philosopher Habermas’s (1981, cited in Mezirow, 1997) distinction between four types of learning: instrumental, impressionistic, normative and communicative, stressing in later work the importance of the distinction between instrumental and communicative learning (Mezirow, 2009). Instrumental learning is concerned with the truth of a proposition and is directed towards learning to control or manipulate the environment or to improve prediction and performance. Its epistemology and its method are hypothetico-deductive. Impressionistic learning is concerned with learning to enhance the impression one makes on others. Normative learning is acquiring the values and behaviour expected of one’s cultural milieu. Communicative learning is discursive or dialogical. It involves at least two people attempting ideally to reach a consensus through a shared understanding of the meaning of an interpretation or the justification for a belief. It involves assessing and understanding the other person’s frame of reference at both an intellectual and an empathic level and to seek common ground by covering the widest range of relevant experience and points of view as possible.
The distinction between instrumental and communicative learning is of particular relevance to CBT in that CBT’s guiding principle is “collaborative empiricism”. Despite its centrality to both the philosophy and method of CBT, Tee and Kazantsis (2011) claim that collaborative empiricism has proved a difficult concept to conceptualise and operationalise as it is not clear whether it is more usefully thought of as a facet of the therapeutic alliance or a therapeutic strategy. CBT techniques use the language of empiricism and elements of the hypothetico-deductive method, for example weighing up evidence in support of propositions (beliefs) that are formulated as potentially faulty hypotheses, or directly testing those beliefs using behavioural experiments. However, collaborative empiricism could perhaps be thought of more in figurative than literal terms. CBT practitioners do not encourage their clients to engage in activities that resemble empirical science as it is actually practised. There is, for example, no psychological Hadron Collider or Hubble telescope. Indeed, it is doubtful that any therapist has ever attempted to set up a behavioural experiment with a client that meets the gold standard for science of the randomised controlled trial, as this would be entirely inappropriate to the essentially interpersonal nature of therapeutic dialogue. The author would therefore argue that in practice, CBT relies on the practice of communicative learning in that client and therapist engage in a collaborative dialogue about the client’s experiences, beliefs, emotions, and behaviours with a view to finding explanations of best fit and greatest utility. CBT is, in essence, more concerned with the adaptive functions of beliefs and behaviour than with correspondence to some independently determined objective reality, if such a reality could be divined when experience is so phenomenologically subjective.
Mezirow (2009) distances transformative learning from the critical pedagogy of authors such as Paulo Freire and from social action to effect social change, such as are described in emancipatory learning approaches. Other authors however have emphasised that an analysis of power imbalances and a critique of the methods by which neoliberal economic systems create and perpetuate inequality is essential to situating educational practice in the lived experience of those that are being taught. Thompson (2000), for example, describes emancipatory learning theory as being unconcerned with strategies for personal self-improvement as its purpose is to help learners develop an understanding of their unsatisfactory social circumstances so that they are able to develop strategies to change them.
There have been a number of attempts to address the role of education and educational practice in working towards social change. Perhaps most notably, Paulo Freire developed a “pedagogy of the oppressed” (1970, 1974) where he proposed that an important function of education was to develop conscientisation (conscientizaçäo in its original Brazilian form). Conscientisation is a method whereby oppressed people develop critical consciousness so that they were able to learn to identify, interpret, criticise and transform the world in which they live through the process of praxis, where praxis is defined as “reflection and action upon the world in order to transform it” (1970, p. 51).
The author would argue that this is a point of view that is important for CBT trainees and practitioners to appreciate in order to help recognise the limits and potential pitfalls of individual treatment. While diagnosis-specific treatment protocols are a bedrock of CBT treatment within IAPT, many clients have a lived experience of mental health problems that is heavily impacted by adverse life circumstances that are the product of systemic injustice and inequality. It has been well documented that the client’s social environment makes a significant contribution to the likelihood both of experiencing significant distress and of seeking help for it and that “the positive association between ‘mental illness’ and poverty is one of the most well established in psychiatric epidemiology” (Mills, 2015, p. 213).
To put that in the context of the UK’s current social circumstances, a report by the Joseph Rowntree Foundation (Fitzpatrick et al., 2020) found that more than a million UK households containing 2.4 million people, including 550,000 children, experienced destitution in 2019, where destitution is defined as adults (or their children) lacking two or more of six essentials over the previous month either because they cannot afford them, or their income is so extremely low that they are unable to purchase them for themselves. The six essentials are shelter, food, heating, lighting, clothing and footwear, and basic toiletries (Fitzpatrick et al., 2016). It is to be expected that CBT practitioners working within healthcare services such as IAPT will regularly attempt to work psychologically with people whose material impoverishment needs to be considered when assessing the suitability of the treatment for the person, rather than the person for the treatment.
A concept of CBT as an emancipatory learning approach treats the social as being of at least equal importance to biological and psychological determinants of wellbeing. It goes beyond individual skilfulness in technique, to developing a reflective practice in which practitioners and their clients are helped to make connections between experience, understanding and social action to bring about social change (Thompson, 2000). If we were to paraphrase Marx’s famous remark that “The philosophers have only interpreted the world in various ways; the point, however, is to change it.” (Marx & Engels, 1845), we might suggest that while therapists may have only interpreted the client in various ways, the point is to help them change their world. Conversely, as Mezirow (2009) points out, critical pedagogy such as Freire’s rarely engages with how challenging it is to change social circumstances, given the degree of organisation required and the resistance of institutional systems to change. Even if social change at a macro level is beyond the scope of the individual practitioner, it is perhaps beholden on us to recognise and advocate for social solutions to socially-induced psychological problems, as well as empowering clients to do the same and to help them see the links between structures of power and personal distress.
In summary, experiential learning models form the theoretical basis for reflective practice, which is the process of developing and maintaining proficiency. Experiential, transformative or emancipatory learning theories can also be used to understand the therapeutic process within CBT. CBT is a psychotherapy that is explicitly concerned with learning, that is with transforming the meaning and understanding of events, in order to empower people to take more control of their lives as a strategy to overcome the distress, functional impairment, stigma and disempowerment of living with a mental health problem.