The central aim of Integrative CBT is cognitive change: change in the way we see things, interpret events, talk to ourselves, pay attention to certain aspects of our environment, put meaning on our lives, etc. This level therefore takes us a step beyond the work of Egan etc, into the specifically cognitive focus at the heart of the model.
There seem to be frequent misunderstandings about this type of work; for those of us who love it, talking about it can sometimes feel like trying to persuade people that they would really like your friend if they only got to know them...
Common misapprehensions range from “Working with cognitions is cold, and is not concerned with emotions” to “Working to change thinking is about persuasion, and is only concerned with getting people to think rationally”. Certainly none of this is true of Beck’s Cognitive Therapy, which is the basis for Integrative CBT.
Focus on cognition can be relatively generic, looking at the way in which we all distort our interpretations of our experience; Ellis’s Rational Emotive Behaviour Therapy and the classic Cognitive Distortions outlined by David Burns are good examples of this. A more individualised Case Formulation can be put together with a client by identifying vicious cycles of thoughts/feelings/behaviours/physiology that are keeping a problem going.
For instance, in a depressed client, their negative thoughts feed their depressed feelings, lack of activity, and exhaustion, and are in turn reinforced by each of these symptoms. Integrative CBT gives attention to all four pieces of this symptom cycle, but is Cognitive-Behavioural in being especially focused on helping the client to make relevant changes in their thinking and in their behaviour, in order to reverse the damaging vicious cycles. Integrative CBT therapists therefore need to be comfortable in working with emotion, behaviour, cognition and physiology. (They also need to be able to work with the roots of these vicious cycles in the client’s past, but I’ll say more about that in next week’s blog).
In recent years, a number of clinicians and researchers have developed models of the typical vicious cycles found in mental health problems such as Depression, Social Anxiety, Panic, OCD, Substance Addiction, etc. The “Overcoming” series of CBT self-help books published by Robinson are a user-friendly way to get up-to date on some of this work. I will also look more closely at some examples in future blogs.
The key change process at Level 3 is what I call Structured and Facilitated Experiential Relearning, or SAFER – hopefully a memorable name, especially because working with anxiety is a particularly good example. When we are overanxious about something (e.g. essay-writing, attending social occasions), we no longer learn from experience in that area, because the cycle of experiential learning has become blocked (we avoid the situation, discount any successes, interpret our discomfort as a sign of failure, etc). When we do manage to make changes in a vicious cycle like this, we do so through Experiential Relearning – discovering through experience that our fears are not well grounded. Sometimes we are lucky, and this process happens without it being deliberately planned or structured (e.g. we find a subject that really interests us, get involved with a new social activity, etc). But when we are really stuck, this process of change requires more Structured Experiential Relearning; a relevant self-help book may provide sufficient structure for some people, but many people need the process to be professionally Facilitated by a therapist.
At this level of Integrative CBT, as in Cognitive Therapy, the learned habits of thinking and behaviour which keep the problem going can be unlearned and replaced through a process of Guided Discovery, using two very powerful therapeutic tools: Socratic Questioning and Behavioural Experiments. Socratic Questioning starts out as a cognitive/empathic process which tries to tease out what beliefs the client has learnt from their life experiences. This then leads into a probing, testing process, where the basis of beliefs are examined and questioned, not just in relation to their truth, but also their current relevance, value, importance, meaning, usefulness etc.
Behavioural Experiments are different from the Behavioural Change work we discussed at Level 2. At Level 2 we focus on identifying, learning and practising “good”, helpful, useful behaviours in areas of the client’s life where this is necessary (e.g. asserting oneself, relaxing, eating more healthily, cutting down on drinking, etc). Behavioural Experimentation, on the other hand, might equally focus on “bad” behaviours (e.g. leaving a task unfinished, not being “nice” to everyone, staying up all night, etc), since just as much, or more, can be learned experientially from the results of such experiments. So Level 2 is about engaging with the environment in order to make changes; Level 3 is about engaging with the environment in order to reality-test and re-learn; the main goal is change in the client’s cognitive interpretations, assumptions etc.
Personally, I love this level of work; it can be very alive, engaging and productive. Consider making friends with it if you haven’t already…