As a counsellor/psychotherapist who had a fairly typically eclectic initial training, I have increasingly specialised in the Cognitive Behavioural approach over more than 20 years of varied experience as a practitioner. CBT currently seems to me to be the most solidly-based psychotherapeutic approach, in both theory and practice. However, I also believe that it is best used in an integrative way, pragmatically incorporating the best of what other approaches have to offer.
I present here a model of Integrative CBT, consisting of five different levels of therapeutic interaction which the therapist may move between, depending on the client’s needs:
Level 1: Therapeutic Relationship
Integrative CBT needs to be first of all grounded in a therapeutic relationship, where skills such as Active Listening, Advanced Empathy etc are used to enable the client to experience the therapeutic benefits of a helping human encounter. Sometimes this is all a client needs: containing, holding, support, validation, a safe space to explore their world and their concerns. For other clients, this working alliance serves as the basis for work at the other levels below.
At this level, much can be learned from Humanistic approaches such as Person-Centred Therapy and Gestalt Therapy.
Level 2: Problem-Solving Action
The next level many clients need, in order to create change in their lives, is the level of problem-clarification and practical action. Here clients can be helped to engage more effectively with their environment by decreasing negative behaviours (e.g. social avoidance, passive/aggressive behaviours) and increasing positive behaviours (e.g. using social supports, asserting oneself). This can be achieved both by introducing them to general principles of change such as goal-setting, planning and reviewing, as well as by introducing specific life-skills training in areas such as stress management, assertiveness, decision-making etc.
A lot of useful material for this level can be found in the Egan Model, Choice Theory, Motivational Interviewing etc.
Level 3: Experiential Re-learning
The next level of intervention which may be needed (especially for those with specific mental health issues such as Depression, OCD, etc) is collaborative, educative Cognitive/Behavioural/Emotional re-learning. This is the heart of CBT, and is based on the work of Beck and Ellis. Here we help the client to untangle self-perpetuating vicious cycles between their Environment, Cognition, Emotion, Behaviour and Physiology, so that they can unlearn what is dysfunctional and learn new, more functional, approaches. This happens through a process I call Structured and Facilitated Experiential Re-learning (SAFER). At this level we use core Cognitive-Behavioural Guided Discovery processes such as Socratic Questioning and Behavioural Experimentation.
Many techniques from other approaches can also be usefully integrated at this level; Mindfulness training is a well-known example.
Level 4: Schema Change
Of course, many clients need longer-term developmental work, involving more detailed life-history exploration and deeper Cognitive/Emotional restructuring at the level of Core Beliefs. This can help clients to gain a broader understanding of the sources of their difficulties, as well as increasing resistance to relapse through lessening the influence of maladaptive Core Beliefs/Schemas.
One approach to this is Jeffrey Young’s Schema Therapy, which is CBT-influenced but also explicitly integrative in its theory and practice, incorporating aspects of Attachment Theory and Object Relations Theory, amongst others.
The equivalent of transference/counter-transference issues can also be explored at this level, within the framework of a Cognitive Behavioural case formulation approach.
Level 5: Coming to Terms with the Human Condition
Since not all difficulties can be resolved through therapy, clients may need help to understand and process the realities of the human condition which necessarily remain. Some of these may be specific to their circumstances and history, or to their particular mental health problems (e.g. long-term health issues, marital separation, wasted career potential, partially-healed trauma). Others arise from the evolved vulnerabilities of our species (e.g. unhealthy appetite for sugar, tendency to fall in love, anxieties regarding status and meaning), or are just part of the essential nature of life (e.g. competition, rejection, risk, loss, old age, death).
Here the therapist tries to help the client towards a greater understanding of themselves as a human being, incorporating whatever perspectives they find helpful, whether philosophical, cultural, scientific, existential, or spiritual.
A relevant approach that has grown out of CBT is Paul Gilbert’s Compassion-Focused Therapy.
Since this level is about humanising the client’s experience, it brings us back full circle to Level 1, where the therapist tries to meet the client non-judgmentally human-to-human.
Over the next few weeks I’ll be expanding on these levels, giving some examples as to their use in practice, then going on to explore various topics relevant to the Integrative CBT approach, such as safety behaviours, vicious circle causality, case formulation, evolutionary theory, and online counselling.
All feedback welcome!