Wednesday, 19 May 2010

Choice and Action – Moving to Level 2 and Beyond

When we move into the problem-solving attitude of Level 2, while still remaining grounded in the therapeutic relationship, we are travelling in the company of influential figures such as Gerard Egan (Skilled Helper model) and William Glasser (Choice Theory). Both emphasise the importance of establishing a warm working relationship, but also understand that clients often need us to add a directional, change-oriented focus, with a commitment to planning and behavioural trial-and-review. At this level, we don’t need to reinvent the wheel, but can happily incorporate the work of the above approaches, as well as others such as Motivational Interviewing and Solution Focused Therapy.

One of the key questions used in Choice Theory, for instance, can be a very powerful Level 2 intervention: “Does your present behaviour have a reasonable chance of getting you what you want now, and will it take you in the direction you want to go?”

The Egan model provides useful material on action skills such as:

Divergent thinking

Goal setting

Decision making

Problem solving

Evaluating knowledge of resources

Using knowledge of how behaviour is changed

Using knowledge of how useful behaviour is maintained

The Motivational Interviewing approach focuses on some similar ideas, as well as emphasising the following (conveniently alphabetical) steps:

Giving Advice

Removing Barriers

Providing Choice

Decreasing Desirability

Practicing Empathy

Providing Feedback

Clarifying Goals

Active Helping

Solution Focused Therapy suggests interventions such as looking at previous solutions, posing the Miracle Question, etc.

Finally, skill-training in specific areas can also be a focus at Level 2. Again, there is already an enormous amount of work available to be integrated, from Assertiveness Training, Stress Management, and many other areas.

So, although this level of work is easy enough to understand conceptually, it is very broad, and there is a lot for the practising therapist to learn about. (There is also a lot of material for future blogs, as many of these areas can be gone into in more detail from an Integrative CBT perspective - just thought I should warn you!)

Having drawn attention to the kind of work which takes place at this level, and suggesting where we can look for practical material we can incorporate, I want to say a bit more about the process of choosing what level to focus on at any particular moment in therapy; I am not just describing a theoretical model here, but how I actually work. This choice can be influenced by many factors: the client’s goals, the stage of therapy, the type of issues, the overall case formulation, and maybe also the therapist’s individual style.

It is possible to look the five levels of Integrative CBT as a progression, and over the whole period of therapy with a client this may in fact be accurate. For example, addiction counselling often moves from developing trust and acceptance, to encouraging practical behaviour-change steps, to challenging underlying addictive thinking, to addressing “Inner Child” issues, to fostering some self-acceptance as a flawed human being. But of course the different levels are not really separate; from moment to moment in each session the therapist may be moving between problem-focus, the state of the relationship, the childhood story, reviewing goals and motivations, noticing the client’s cognitive distortions, trying to validate and humanise what is happening, etc.

Yes, it does get more complicated once you try starting to problem-solve with a client, while also keeping an eye on the integrity of the therapeutic relationship; and it gets even more complicated when you add in some cognitive restructuring and developmental exploration. Of course it is easier if you take an approach which concentrates on just one of these – but is that good enough for the client? Well, it depends on the issues. Some clients may just need some problem-solving, skill-learning assistance; they may not even need much attention paid to the therapeutic relationship, just the minimum necessary for a working alliance. On the other hand, clients with specific mental health issues such as OCD or anger problems may need to postpone much of this kind of practical work until they have learnt to think and feel differently about their problems through cognitive-behavioural re-learning at levels 3 and 4; otherwise they may be trying to solve the wrong problems (e.g. their co-workers’ unhygienic habits, their spouse’s high expectations!).

One final point: this level is about action, behaviour change, helping the client to have a more positive influence on their environment. It can therefore be seen as more “directive”, often a controversial term. The therapist should not tell the client what to do with their lives, but sometimes they do need to be quite direct in supporting the client to find the direction they want to move in, and to test out ways of moving in that direction. I’m happy to travel that journey with my clients.

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