Some Thoughts on Elephants, Integration and Fish…

I’m going to postpone the first case example until next week, and prepare the ground a bit by summarising what I have been saying about Integrative CBT.

The Buddha tells the story of a king who had six blind men gathered together to examine an elephant. When the blind men had each felt a part of the elephant, the king went to each of them and said to each: 'Well, blind man, what sort of thing is an elephant? The blind men assert that the elephant is either like a pot (the blind man who felt the elephant’s head), a wicket basket (ear), a ploughshare (tusk), a plough (trunk), a granary (body), a pillar (foot), a mortar (back), a pestle (tail) or a brush (tip of the tail). The men cannot agree with one another and come to blows over the question of what an elephant really is like...

In a similar way, various psychotherapy schools tend to emphasise different factors which can lead to therapeutic change – awareness (Gestalt Therapy), working with Transference (Psychodynamic Psychotherapy), Cognitive Restructuring (CBT) etc. Each approach has its own idea of what a client most needs. Because no single approach has yet been found to help all clients with all issues in all situations, eclecticism has also gained a strong footing in the psychological therapies, along with attempts to achieve a more integrated approach. My experience is that clients need us to be able to work flexibly at a variety of levels, hence my attempt at a more integrative approach.

To be genuinely integrative, rather than just eclectic, an approach needs to be based on a core theory of therapeutic change. Following Beck, the core change in successful Integrative CBT is understood to be cognitive change. While this change may need to be facilitated by the direct cognitive restructuring techniques of traditional CBT (Level 3 Integrative CBT), it equally may require a containing relationship (Level 1), problem-solving tools and direction (Level 2), developmental exploration, including at a transferential level (Level 4), and some attempt to set problems and recovery within the context of the human condition (Level 5). A case is therefore formulated in primarily cognitive terms (i.e. beliefs and other cognitions are seen as the main determiners of emotions, behaviours etc), but the primary work may be at any or all of the five levels described. This clearly involves a wide skill-set, if the therapist is to be flexible enough to meet a client at any of these levels.

One last point on why this particular integration is built around CBT (leaving aside the fact that it has a stronger scientific basis in both theory and research):
The idea of ongoing work by the client in between sessions (often unfortunately called ‘homework’) is a key aspect of what makes this approach effective. Remember, this is all about experiential re-learning, which needs to take place outside the therapy room at least as much as within it (probably more so). So skills practice, recording of thoughts, behavioural experiments etc are just ways of continuing the therapeutic work in the time between sessions, and often in the settings where it is most relevant. To get this sort of continuity, and some cumulative therapeutic benefit, is not easy. In fact, it is one of the greatest challenges in therapy. But it is also one of the greatest gifts we can give to a client. You know the story about giving a man a fish, versus giving him a fishing rod and teaching him to fish...

I started with an elephant, now I’m on to fish...better sign off for now!