Integrative CBT

A Sea of Troubles – Emotional, Behavioural & Cognitive Themes in Anger, Anxiety and Depression

2011-06-07T09:56:00.000+01:00

Whether 'tis nobler in the mind to suffer the slings and arrows of outrageous fortune,

Or to take arms against a sea of troubles, and by opposing end them? – Shakespeare

A useful way to approach problems of anger, anxiety and depression is to see them not so much as separate issues, but as different kinds of response to ongoing frustration of the achievement of our goals, and to the sense of threat, stress and pressure that this brings. They are all potentially adaptive responses, as they are based on the evolved fight/flight/freeze system, but of course they can also be maladaptive.

Let’s think about them first from an emotional/behavioural point of view. We will look more closely further down at the cognitive themes which these feelings and behaviours would suggest.

Ongoing frustration of important goals, for instance failure to secure a job despite our best efforts, can first of all make us feel angry, but we don’t necessarily feel very fearful or demotivated yet. The anger we feel can give us energy for the fight, and determination not to be beaten. Of course it may also make us irritable and demanding, which may not help the situation.

Continued efforts without improvement may begin to frighten us – we start to sense that further fight may bring no change in our situation, and we may begin to feel threatened, to feel that our goals are really in danger. This can make us understandably very anxious, especially if these goals are fairly fundamental ones, such as making enough money to live, protecting our children, keeping ourselves healthy, hanging on to an important relationship etc. Again, these feelings can be adaptive, by helping us to be cautious and realistic, or they may just undermine our faith in our ability to cope, especially as we become more and more conscious of the fact that we are anxious. In the anxious state, however, we still feel some hope along with the doubt, feeling at least some of the time that it is worth while trying to re-engage with the struggle. We feel like running away, and may indeed do so some of the time, but we don’t give up completely.

If we lose this thread of hope, feeling that the struggle is no longer worth it, we find ourselves in the depressed state. This is the frozen, numb state, where caring about anything seems futile (as it seems like it cannot be achieved anyway), and any signs of hope, or even of success, are dismissed as illusory. We therefore don’t really try anymore, further reinforcing our lack of goal achievement. This is generally seen as a maladaptive state, and its possible adaptive function is less clear, but it may be

• An evolved mechanism of distress telling us to hibernate, escape or change something

• A signal that our coping system is overwhelmed and that we need time out

(http://www.psychologytoday.com/articles/200310/where-did-depression-come)

As I mentioned above, it is interesting to look at these three states from a cognitive perspective, as Beck does (e.g. Beck, A.T., 1976, Cognitive Therapy and the Emotional Disorders. New York: International Universities Press). The thinking described here may of course be realistic or unrealistic, functional or dysfunctional, to whatever degree.

Cognitively, the angry state reflects themes of perceived offense/transgression, rooting itself in the belief that something is wrong, unjust, unfair, and needs to be put right. Angry thinking and self-talk are characterised by phrases such as “should”, “ought”, “no right to”, “fault”, etc.

In the shift to the anxious state, we still see things as being wrong in some way, but we begin to see some aspect or aspects of the situation as more dangerous/threatening than we did, and our ability to cope with it as being less than we did. There is still a sense of defensiveness, but along with it a greater sense of vulnerability, and therefore our self-talk becomes less like fighting talk, and more safety-oriented: “what if?”, “I’d best not”, “I might fail” etc.

If the angry state is characterised by the view that some bad outcome shouldn’t happen, and the anxious state by the view that it looks as if it might happen despite our best efforts, then the depressed state sees it as having happened, actual loss rather than threatened loss, actual failure rather than possible failure. Furthermore, the depressed person can see no likely change to that situation, so their perspective is also one of futility; effort seems pointless, as there appears to be no real prospect of any significant action being rewarding.

Of course, there are ways out of this state, and they involve the reversal of the path we have just traced.

If efforts are to be made by the depressed person, especially in the important areas of life where they have experienced such disappointment and frustration, then these efforts need to be ones which lead to some feeling of reward (CBT therefore always starts with small, doable yet significant activities, such as getting a little bit of fresh air and exercise).

As a person begins to feel less depressed, and starts to look at their world again as maybe being a place of possibility rather than impossibility, the possibility of things going wrong again looms for them, and it is very common to move from depression back into anxiety. This is so uncomfortable that it can send many people back to depression again, so the therapist needs to make sure the client is ready for this, and help them shift the focus of the therapeutic work to the different themes of this state.

What is less obvious to many people is that if they are to re-engage with the life issues which were causing them so much stress, they may well need to revisit the angry state. This is normal, but it may need to be normalised for some clients. There may be dysfunctional expectations involved in their anger, and these may need to be worked on, along with learning more assertive ways of approaching life challenges. But there is also potentially useful energy in the angry state, and we may need to be reminded that anger is often a valid emotion if we are to step into the sea of troubles once again.

Where Are We Now? – Reviewing Therapeutic Progress Using the 5 iCBT Levels

2011-05-03T23:41:00.000+01:00

The 5 Levels of Integrative CBT outlined in these blogs can be a useful tool for reviewing where therapy is going, especially if it is stuck. This is something a therapist can carry out in their own mind as they reflect before and after sessions; it can also take place as an explicit discussion between therapist and client; or it can happen, of course, in supervision, which can make Integrative CBT another useful model for supervisors.

Level 1:

This is the primarily Relational level, where the focus is on immediacy of contact and connection with self, therapist, and others.

Useful review questions on this level are:

How solid is the therapist-client contact? Has it been well-established to start with? Does it need to be revisited/re-established?

How solid is the client’s contact with themselves? Can they access relevant feelings?

While Integrative CBT practitioners don’t believe it is sufficient in most cases for the therapeutic focus to stay solely on the relational level, we do run the risk of losing sight of this level as we get engrossed in problem-solving, cognitive restructuring etc (see 12^th May 2010 blog: http://integrativecbt.blogspot.com/2010/05/exploring-level-1-therapeutic.html).

So it certainly needs to be part of the ongoing review which this approach favours (see 27^th October 2010 blog: http://integrativecbt.blogspot.com/2010/10/continuity-and-collaboration-role-of.html).

Level 2:

This is the level of Problem-Solving.

Useful review questions on this level are:

What practical issues in the client’s life/environment may be in need of more attention than they are getting?

Does there need to be a review of goals? Of resources? Of motivation?

Are there skills such as assertiveness or relaxation that the client is in need of in order to move ahead?

Often this is the most important level to come back to when therapy doesn’t seem to be progressing. It may be that a clear sense of direction has been lost – goals, targets, strategies, commitments may need to be revisited, and even revised if necessary.

Level 3:

This is the level of Cognitive-Emotional Re-Learning.

Useful review questions on this level are:

What blocks to therapeutic progress have arisen at Level 2 which might suggest that particular vicious cycles may be in operation? Do any of them suggest a specific mental health diagnosis such as depression, an anxiety disorder, an addiction, etc?

What aspects of a cognitively-based case formulation need to be put in place/revisited?

Are there specific negative automatic thoughts or cognitive distortions in play that haven’t been identified yet? Specific safety behaviours?

Often what needs reviewing at this level is the case formulation, and sometimes what needs to come more clearly into focus is an “off-the-shelf” case formulation, in other words a diagnosis. Sometime the reason that clients cannot make the necessary changes at a problem-solving level, despite their best efforts, is that they are struggling within a particular pattern of vicious cycles between specific cognitions, behaviours and emotions; sometimes this pattern already has a name e.g. Social Anxiety, Depression, Alcohol Dependence. If this is the case, there will not be much progress until both client and therapist become clear about it.

Level 4:

This is the level of Schema Change.

Useful review questions on this level are:

Is it necessary/desirable for the therapeutic work to go deeper, to address schemas/core beliefs?

How clearly named are the relevant schemas/core beliefs? Would a Young Schema Questionnaire be useful?

At the very least, more explicit exploration and naming of schemas/core beliefs can help to pull together a coherent case formulation. Deeper healing and resistance to relapse can also come from more direct work on softening/diluting the power of maladaptive schemas – however, this is long-term work by its very nature, and clients may need to make a difficult decision about the trade-off between investing further in therapy, and getting on with the improvements they have gained.

Level 5:

This is the level which looks at Embracing the Human Condition.

Useful review questions on this level are:

What THEMAs (Typical Human Evolved Motivational Axes such as Mating, Status, Affiliation, Territory etc) are most relevant at this point in the client’s life? (See 25^th March 2011 blog: http://integrativecbt.blogspot.com/2011/03/more-than-you-might-think-getting-to.html and Psychotherapeutic Naturalism blog 20^th March 2011: http://psychotherapeuticnaturalism.blogspot.com/2011_03_01_archive.html).

Which of the client’s needs can perhaps be more fully met, and which ones are more a matter of adjusting their expectations to reality?

Does the client need to look more closely at the values/philosophy they hold, in order to get a clearer perspective on their larger goals?

Reviewing at this level can be surprisingly practical, and not as abstract as it might sound. There is very little point putting great effort into moving forward, if you aren’t facing in the direction in which you want to go!

Comfort Zones – How Much of our Lives Consist of Safety Behaviours?

2011-04-07T07:52:00.001+01:00

The concept of Safety Behaviours (or Safety-Seeking Behaviours) is a familiar one to those working with anxiety from a CBT perspective.

According to David M. Clark (1999),

Salkovskis (1988, 1991) defined a safety-seeking behaviour as ``a behaviour which is performed in order to prevent or minimise a feared catastrophe'' and suggested that such behaviours often explain why the non-occurrence of a feared event fails to change patients' negative beliefs. For example, in the case of cardiac concerned panic patients, he suggested that they continue to think that they might die in a panic attack because every time they have panic attacks, they sit down, rest, slow down their breathing or engage in some other safety-seeking behaviour and believe, erroneously, that performing the behaviour is the only reason they did not die.

Clark goes on to give the following examples of safety behaviours associated with a patient's fear of blushing. First he describes the feared outcome, then the safety behaviours intended to prevent that outcome:

``My face (and neck) will go red.''

Keep cool (open windows, drink cold water, avoid coffee, wear thin clothes).

Avoid eye contact. If in a meeting, pretend to be writing notes.

Keep topic of conversation away from `difficult' issues.

Tell myself the man isn't really attractive; ``He's no more than a 2 (out of 10) for attractiveness''.

``If I do blush, people will notice.''

Wear clothes (scarf, high collar) that would hide part of the blush.

Wear make-up to hide the blush.

Put hands over face; hide face with long hair.

Stand in a dark part of the room.

``If people notice, they will think badly of me.''

Provide an alternative explanation for the red face; e.g. ``it’s hot in here'', ``I'm in a terrible rush today'', ``I'm recovering from flu'', etc.

The key disadvantage of safety behaviours, of course, is that they prevent disconfirmation of catastrophic beliefs, by making sure that they don’t get tested against reality. We never find out what would happen if we didn’t cover up the blush, if we said what we really think, if we drank from a cup someone else had touched.

Over their lifetimes, anxiety sufferers often engage in broader strategies of safety-seeking, which simply become part of their lifestyle. A socially anxious person, for instance, may choose their hobbies, their friends, even their spouse, in a way which is designed to protect themselves from social danger (i.e. negative judgment). Their hobbies may be solitary, their friends may be undemanding and task-oriented, their spouse may be happy to mostly stay at home and to concentrate on the domestic side of their lives.

Joining a religious group may also be a tempting safety-seeking strategy for some people, as there is usually a strong focus on group-belonging, and on directing negative judgments at people outside the group rather than within it.

The workaholic high-achiever, to take another example, seems to have found a way to guarantee positive rather than negative judgments from their peers. Of course, like all such strategies, this tends only to work in the short-term, bringing other problems in the longer-term, such as damage to family relationships, burnout etc. On the other side of the coin, the stay-at-home example above may also lead to its own negative career consequences, due to poor social networking skills etc.

There is food for thought here: to the extent that any of us are socially anxious and feel the need to ward off negative judgment, how much may we have built our lifestyles around this need?

Finally, widespread safety behaviours can also be found outside of these more individual examples. Superstitious behaviours, which are very common in most human populations, are classic examples of safety behaviours: touching wood is definitely ``a behaviour which is performed in order to prevent or minimise a feared catastrophe'', as is avoiding the number 13, and so many other everyday superstitious behaviours.

Perhaps the concept of Safety Behaviours needs to be a familiar one to all of us, and not just those working with anxiety…

References, further reading

Clark, D.A. & Beck, A.T. (2009) Cognitive Therapy of Anxiety Disorders. New York: Guilford Press.

Clark, D.M. Anxiety disorders: Why they persist and how to treat them. Behaviour Research and Therapy 37 (1999)

Vyse, S. A. (2000) Believing in Magic: The Psychology of Superstition. USA: OUP.

More Than you Might Think – Getting to Know Cognition Better

2011-03-25T07:48:00.000Z

Judith Beck (1995, p. 1) defines the Cognitive Model of emotional disorders as follows: “…the cognitive model proposes that distorted or dysfunctional thinking (which influences the client’s mood and behaviour) is common to all psychological disturbances.”

There are many misunderstandings about the role of cognition in psychotherapy, for example:

The notion that cognition is disconnected from emotion. The reality is that, except in the case of specifically abstract thought, they are intimately connected – think of the panic that instantly accompanies the thought/belief “I’m having a heart attack”.

The notion that working with cognition is somehow optional in psychotherapy practice. In fact, given that the term “cognition” refers to something very central to human experience, namely the constant processing of information that informs our responses to our world, it should feature very strongly as a focus for therapeutic change. As Aaron Beck has remarked, "If beliefs do not change, there is no improvement. If beliefs change, symptoms change.” (American Psychological Association, 108th Convention, Washington DC, August 4-8, 2000).

However, the misunderstanding I mainly want to explore in this month’s blog is the idea that cognition is superficial and shallow. The truth is that it is deep and multi-layered; below I describe the various layers where we can see cognitive processes acting.

The most basic level of information-processing is the matter of where we direct our Attention. We are only cognitively and emotionally affected by a particular aspect of our environment to the extent that we notice it, pay attention to it. A socially anxious person, for instance, tends to notice and attend to the expressions on people’s faces, scanning for any possible signs of disapproval; an alcoholic notices where the drinks are kept.

A particular focus of attention such as the above can then trigger relevant Self-talk/Automatic Thoughts. The socially anxious person might be thinking “They don’t like me, maybe I said something stupid”; the alcoholic might be thinking “I’ll never get through the evening without a drink.” Aaron Beck describes his discovery of Automatic Thoughts which “…appeared to emerge automatically and extremely rapidly…prior to experiencing the emotions” (1976, p. 33). Such automatic thoughts, which clients are normally unaware of, but which they can be trained to become more aware of, make sense of the troublesome feelings which immediately follow them. The socially anxious person’s automatic thoughts (ATs) will make them more anxious and self-conscious; the alcoholic’s AT’s will increase their craving.

However, we don’t all have the same ATs about the same situations, so our individual ATs must be influenced by certainly underlying Assumptions/Rules. These are less accessible to present-moment phenomenological awareness than ATs, but can be deduced from the way we habitually respond to situations, cognitively, emotionally and behaviourally. For instance, if the socially anxious person tends to agree with everything that other people say (like the Paul Whitehouse character in the 90s BBC TV sketch comedy “The Fast Show”), we can deduce that amongst their underlying assumptions/rules are things like “no one must dislike me” and “no one will dislike me if I don’t disagree with anyone.” Typical human Cognitive Distortions such as Emotional Reasoning, Black-and-White Thinking and Catastrophisation are also found at this level.

At a deeper level again we find our Core Beliefs/Schemas, as described in a previous blog (“A Client with a Past: Schema-based Case Formulation” - 2 June 2010):

Our earlier learning experiences leave us with deeply held ways of viewing the world, ourselves, and others, ‘templates’ through which we process current experience, and which therefore tend to be self-perpetuating and rigid in nature... These templates can be called Schemas; their contents (e.g. “I’m unlovable”, “Men can’t be trusted” etc) can be called Core Beliefs.

Core Beliefs are more unconditional than Assumptions, as the examples above show.

And finally, in a recent blog on Evolutionary Psychology at

http://psychotherapeuticnaturalism.blogspot.com/2011/03/trials-and-themes-what-makes-humans.html

I discussed the concept of “THEMAs”:

Evolutionary psychology sees human life, like that of any organism, as consisting of strategic attempts to maximise our success along various key axes, such as mating, care-giving, satisfying appetites etc… There is no definitive list (yet) of these motivational axes, but I have put together a list for myself for practical use in the therapy context, which probably covers the main areas… I find it useful to call these major themes in human life “THEMAs” (Typically Human Evolved Motivational Axes). Themas can be seen as analogous to schemas, but operating at an even deeper level, in the way that they structure our lives without us being aware of the fact most of the time. Schemas operate at the level where we are not generally aware how much they structure our experience as individuals. Themas operate at the level where we are not even generally aware how much they structure our experience as a species.

… I list below what I see as the main Themas using the mnemonic “PASTMARKS”.

Parenting

Attachment

Safety

Territory

Mating

Affiliation

Reciprocity

Kinship

Status

So there may be more to cognition than meets the eye – hopefully this has given you food for thought!

References

Beck, A.T. (1976) Cognitive Therapy and the Emotional Disorders. New York: International Universities Press.

Beck, J. (1995) Cognitive Therapy: Basics and Beyond. New York: Guilford Press.

Using Language for Leverage: Metaphors in Integrative CBT

2011-02-07T11:58:00.005Z

Metaphors are something we all use in our communication, to describe, to convey subtle meanings, to give a different perspective on something, and they are therefore found in all approaches to psychotherapy. We would expect them to be particularly central to CBT, as it is fundamentally about clarifying and changing views, perspectives and meanings. The cover of a recent book by Stott. R., et al (2010), Metaphors in CBT: Building Cognitive Bridges (Oxford: OUP), puts it well: “The business of Cognitive therapy is to transform meanings. What better way to achieve this than through a metaphor?”

For more information on this book see

http://www.amazon.co.uk/Oxford-Guide-Metaphors-CBT-Behavioural/dp/0199207496/ref=sr_1_1?s=books&ie=UTF8&qid=1290151525&sr=1-1

There are many examples of metaphors which we all use in therapy, both deliberately and unconsciously. To get a feel for some of them, we can look at them in the context of mental health problems such as depression, anxiety and addiction (further below I will explore metaphors in the context of the 5 levels of Integrative CBT).

Depression

Some metaphors commonly used by both client and therapist to convey the lack of reward and motivation experienced in depression are:

“Swimming through treacle”

“Living in darkness”

“Carrying a heavy weight”

“Being surrounded only by cold, no sign of warmth, endless winter”

“Digging yourself deeper into a hole”

“Turning your face away from life”

“Letting go of the grip you have on the ledge”

The last three are relevant for understanding the self-perpetuating nature of the problem, and for indicating possible ways out, i.e. by not digging, but turning around, by hanging on until help comes…

Anxiety

In talking about anxiety and fear, the metaphors will naturally be threat-oriented and risk-oriented, for example:

“Like living in a war zone”

“The burglar alarm is too sensitive, always getting triggered”

“Always on red alert”

“On stage, under the spotlight”

“Feeling paralysed, unable to make any moves”

The challenge for the client, in the context of metaphors like these, is to lower the level of alert, ignore and eventually recalibrate the burglar alarm, and learn that, even though life will always have risks and threats, the war is over.

Addiction

The experience of addiction has of course many metaphors attached to it:

“The monkey on your back”

“Selling your soul to gambling/alcohol/porn etc”

“Being eaten away by addiction”

“Living in the shadows”

“A garden being overgrown by weeds”

The good news, of course, is that addicts can gradually come out of the shadows, start pulling up the weeds and planting something better, and even reclaim their soul.

We can also look at the metaphors we use when discussing the process of therapy with our clients. While we may be comfortable with professional language such as “Behavioural Experimentation”, clients usually relate more easily to more everyday language such as “Reality-testing”, or better still to metaphors such as “Sticking your toe in the water”.

For the therapeutic process in general, we use images such as

Building a house - digging foundations, putting up walls and roof

Gardening - weeding, planting, watering

Sports injury - rest, physiotherapy, small steps

More specifically, we can look at what metaphors might be useful in discussing the 5 levels of the Integrative CBT model:

Level 1: Therapeutic Relating

Creating a safe space

Holding

Unpacking our baggage

Leaning on someone else for support

Creating the best conditions for growth, like with a plant

Level 2: Practical Problem-Solving

Putting petrol in the car

Making a map of the territory

Getting a clearer picture of where we want to get to

Checking our stock of resources for the challenge ahead

Profit and loss account in relation to motivation for and against change

Checking whether our investments are still worth the effort, cutting our losses if necessary

Level 3: Cognitive-Emotional Re-learning

Stuck in a rut, going around in circles

Opening the bonnet to see what’s happening inside

Untangling knots in our thinking

Looking at the bigger picture

Getting out of our own way

Reclaiming lost territory

Getting back up on the bike

Experimenting with a different style of serve, golf swing etc

Level 4: Schema Change

Seeing life through coloured glasses

Digging deeper

Undergoing an operation

Checking our operating systems for bugs

Scripts, models, programmes etc

Acting out old scripts (including between client and therapist)

Schemas as committee members – some may have a loud voice, but they only have one vote each

Level 5: Embracing the Human Condition

Human life as a journey

Challenges as adventures

Climbing a mountain – hard work, but great view, best not done alone

All in the same boat

And finally, the weather! – it comes and goes, we can’t influence it, only prepare for it

There is no doubt that such metaphorical language benefits both therapist and client, adding a richness and energy (more metaphors there) to the therapeutic dialogue, which can then be harnessed (and again!) for positive change.

I Wish I Wanted to, But I Don’t – The Problem of Motivation for Change

2011-01-19T08:32:00.002Z

As it is the start of a new year, I thought a good topic to get this blog restarted would be that of sustaining motivation for change. From the perspective of Integrative CBT, this is a Level 2 issue; a therapeutic relationship (Level 1) is necessary for many people who need to make difficult changes in their lives, but it is rarely sufficient without other therapeutic factors.

Clients want help, want things to change, and this is what leads them to engage in a therapeutic relationship. However, some changes are hard to make, and even harder to maintain, and many clients become less enthusiastic, even drop out of therapy, once they begin to realise the amount of work that is actually necessary in order to achieve lasting change. They discover (as do therapists) that willpower not enough, that direct persuasion is not productive, that readiness to change is not a fixed quality, and that we can influence, but not control, our deeper, more instinctual motivations and appetites. However, these discoveries don’t seem to stick, so this can be a repeating pattern. The mixed feelings displayed here are therefore not something exceptional, but a normal part of the change process. Our attitude to certain kinds of change (the ones we know are good for us, but which we don’t feel like doing), must by its very nature be characterised by ambivalence.

“Ambivalence takes the form of a conflict between two courses of action (e.g., indulgence versus restraint), each of which has perceived benefits and costs associated with it.”

http://www.motivationalinterview.org/clinical/whatismi.html

The best approach to the issue of ambivalent motivation is still Motivational Interviewing (Miller & Rollnick, 2002, Guilford Press), which was originally developed in response to addiction problems, but is now seen as relevant wherever there are difficult changes to be made. A good example of this is in OCD, where clients are similarly both desperate for change and terrified of change.

The main principles of Motivational Interviewing (MI) are straightforward enough, but they are still worth reminding ourselves about regularly:

1) Express Empathy

2) Develop Discrepancy

3) Roll with Resistance

4) Support Self-Efficacy

Especially useful is the classic Stages of Change model which Miller & Rollnick incorporated from Prochaska & Di Clemente:

MI suggests that people normally move back and forward between the stages many time before achieving lasting change, that we can only help someone if we work with them at their current stage right now (not the one which we or they think they should be at), and that we can only move forward one stage at a time. The Determination/Preparation stage is especially crucial, as it emphasises realistic planning and expectations, and is exactly the stage that is given insufficient attention by most people. It is worth emphasising with clients that there may need to be substantial change in their overall lifestyle, and in specific daily routines and rituals, in order to achieve changes in the areas they have targeted. The classic question to explore is “What else do you need to change in order to change X?”

MI is not a new set of skills/techniques as such, but a perspective we take – all our current skills of empathic listening, Socratic questioning etc are as relevant as ever, but are harnessed in the service of exploring and strengthening motivation, which MI reminds us should never be taken for granted.

I would encourage all therapists to have some familiarity with this approach, and I find that it dovetails particularly well with an Integrative CBT style of therapy.

*******

Speaking of changes, this blog will be posted monthly from now on, but I am also starting another monthly blog about the relevance of Naturalism to psychotherapy, under the heading Psychotherapeutic Naturalism - see http://psychotherapeuticnaturalism.blogspot.com/

I will be exploring topics such as the role of science in psychotherapy, the problems of choice and free will, the nature/nurture debate etc. Hope to see you there!

Self-care break in blogging until the New Year

2010-12-08T16:22:00.000Z

Hi all

I've been away from the blog desk for a couple of weeks, due to a bereavement in the family.

I'll stay away until the New Year, like a good self-care role model should!

See you then - have a good one...

Eoin

Labels, Boxes, Maps – The Question of Diagnosis

2010-11-18T07:30:00.001Z

I believe that CBT is at its strongest, and most proven, when tackling specific mental health diagnoses such as depression, social anxiety, sexual addiction, etc. However, diagnosis and classification is a controversial topic within the field of counselling & psychotherapy, and many therapists question the status of such diagnostic categories, whether found in the DSM-IV or not. Rogers (1951, p. 223), for instance, considers that ‘a diagnosis of the psychological dynamics is not only unnecessary but in some ways is detrimental or unwise.’ The other extreme view is strongly represented within the addiction counselling field, where many counsellors see addictions as discrete 'disease' entities, following the view set out by Alcoholics Anonymous (Alcoholics Anonymous, 1976; Thombs, 1999), rather than as being on a continuum of behaviours, feelings and thinking shared by all human beings (and even by other animals). While I hold the continuum view of addiction, and of mental illness in general (Gilbert, 1992), I also feel that some sort of classification is helpful, and that it is important to try to define entities such as depression etc, albeit not in a rigid way.

Some of the controversies involved might be resolved by looking at the idea of definitions in general in a less rigid way. Finch (1995, p. 35) describes how Wittgenstein queried the notion ‘… that concepts should have definite and clearly bounded meanings, each concept only applying to all the things that have a particular definite feature in common.’ It is hard, for instance, to find any common denominator for all the things called pictures or games. Rather than requiring common features in the definition of a concept, Wittgenstein suggested that the presence of ‘family resemblances’ is sufficient; this means that different instances of a concept share some overlapping features with others, but there is no single common feature (Finch, ibid.; Vyse, 1997). Many definitions of mental health problems seem to fit this description quite well.

Carl Jung was of the opinion that ‘Clinical diagnoses are important, since they help give the doctor a certain orientation; but they do not help the patient. The crucial thing is the story’ (1963, p. 145). I would strongly disagree with this, as my experience is that a definite diagnosis is often very welcome to clients, helping to name and normalise their problems, to “put some shape on them”. However, this does not mean that I necessarily support the "Disease Concept" of addiction (Thombs, 1999; Peele and Brodsky, 1991; Miller and Rollnick, 1991). Peele in particular (1998) has argued for a view of addictions that sees them as real entities, which are nonetheless on a continuum with non-pathological experience. Similarly, Gilbert (1992) suggests that the Disease-Centred, “Platonic” approach to mental disorders such as depression (seeing them as qualitative variations from the normal), which was pioneered by Kraepelin in the early 20th century, is only one possible approach. The alternative Person-Centred or Biopsychosocial approach, where disorders are seen as quantitative variations from the norm, Gilbert traces back to Hippocrates.

Such diagnostic classification addresses our need to be able to approach problems in a systematic way. Orme (1984, p. 68) contends that ‘…anyone thinking he can help someone who is in psychological difficulties, who cannot at the same time systematically label those difficulties, is going to be as much use as a surgeon trying to set a broken limb with no knowledge of anatomy.’ Similarly, research into a particular disorder requires mutually agreed definitions. On the other hand, psychological difficulties may be less objective, and more socially constructed, than are anatomical distinctions. Young points out that diagnostic technologies such as the DSM-IV ‘… are an integral part of the historical formation of some of the disorders … that they now identify and represent.’ (1995, p. 107).

The bottom line for me is that many clients seem to find an appropriate diagnosis, along with education in the relevant Cognitive-Behavioural model, very relevant to some of their mental health problems. It provides them with both a map of the territory in which they find themselves lost, and a highly motivating sense of identification with others in a similar predicament.

References

Alcoholics Anonymous (1976) Alcoholics Anonymous. New York: A.A. World Services.

Finch, H.L. (1995) Wittgenstein. Shaftesbury, Dorset: Element.

Gilbert, P. (1992) Depression: The Evolution of Powerlessness. Hove: Erlbaum.

Jung, C.G. (1963) Memories, Dreams, Reflections. London: Fontana.

Miller, W.R. and Rollnick, S. (1991) Motivational Interviewing: Preparing People to Change Addictive Behaviour. New York: Guilford.

Orme, J. E. (1984) Abnormal and Clinical Psychology: An Introductory Text. London: Croom Helm.

Peele, S. (1998) The Meaning of Addiction: An Unconventional View. San Francisco: Jossey-Bass.

Peele, S. and Brodsky, A. (1991) Love and Addiction. New York: Taplinger.

Rogers, C.R. (1961) On Becoming a Person: A Therapist’s View of Psychotherapy. London: Constable.

Thombs, D.L. (1999) Introduction to Addictive Behaviours. 2nd edn. New York: Guilford Press.

Vyse, S.A. (1997) Believing in Magic: The Psychology of Superstition. Oxford: Oxford University Press.

Young, A. (1995) The Harmony of Illusions: Inventing Post-Traumatic Stress Disorder. Princeton, NJ: Princeton University Press.

Help Yourself: The value, or otherwise, of self-help books.

2010-11-03T07:46:00.002Z

I was recently involved in a discussion on this topic on the Dave Fanning Show (30^th October, 2FM), and I thought it would be useful to share some thoughts here. I often recommend and make use of self-help books, but I am also wary and critical of them, as they aren’t all helpful, and some may even be damaging.

First of all, I am a fan both of self-help (in fact, I think therapy should ideally be a kind of facilitated self-help) and of books (as anyone who knows me will know), so “self-help books” sounds like a match made in heaven. However, I think real self-help books need to be distinguished from those that are just inspirational, and self-help books which are based on sound psychology need to be distinguished from those that probably aren’t. And, of course, even the best self-help books need to be used, and their suggestions practiced, not just read and admired (sometimes, I think, they are not even read, just bought with the proverbial good intentions and left on a shelf to be examined thoroughly “someday”).

The best self-help books are concrete and specific, challenging as well as supportive, not overly “dumbed-down”. And they don’t claim to be earth-shatteringly new; on the contrary, any plausible self-help book should claim to be in line with current best practice in the area it addresses (e.g. improving confidence, healing relationships, achieving more career-wise, reducing anxiety, or whatever).

More specifically, many of the best ones are based on some version of CBT principles. Positive Psychology and affirmations, for instance, are not enough on their own to effect real change in most circumstances. And changes in our thinking can only change our behaviours and emotions, it can’t directly change objective reality. And there are limits in life - many things are impossible. Any other view can just raise false hopes, leading to increasing disappointment rather than positive change, and often to guilt and self-recrimination for not “getting it right”.

I should finish by making some helpful suggestions…

Here are some self-help books I think are amongst the better examples of the genre, including some that go way back:

Weekes, C. (1995) Self Help for your Nerves. Reissued edition. Thorsons.

(First published in 1962).

Scott Peck, M. (2008) The Road Less Travelled: A New Psychology of Love, Traditional Values and Spiritual Growth (Classic Edition). Rider.

(First published in 1978).

Jeffers, S. (2007) Feel the Fear and do it Anyway. 20th Anniversary edition. Vermilion.

Burns, D.D. (1998) Feeling Good – The New Mood Therapy. 2nd edition. Avon Books.

Burns, D.D. (1989) The Feeling Good Handbook. New York: Plume.

Davis, M. et al (1995) The Relaxation & Stress Reduction Workbook. 4th Revised edition. New Harbinger Publications.

Neenan, M. (2009) Developing Resilience. London: Routledge.

A couple of good Irish ones:

Tubridy, A. (2008) When Panic Attacks. Gill & Macmillan.

(Burns, incidentally, has a book with the same title).

Bates, T. (1999) Depression: The Commonsense Approach. Newleaf.

And here are some that I currently recommend to clients:

Kennerley, H. (2009) Overcoming Anxiety: A self-help guide using Cognitive Behavioural Techniques. London: Robinson.

Gilbert, P. (2009) Overcoming Depression: A self-help guide using Cognitive Behavioural Techniques. London: Robinson.

Davies, W. (2000) Overcoming Anger & Irritability: A self-help guide using Cognitive Behavioural Techniques. London: Robinson.

There are many others in the Overcoming series which may be useful depending on the issues – check them out

That’s all for now. There will be no blog next week, as I will be on holidays. In the meantime, help yourself, read a book…

Continuity and Collaboration: the role of "reviewing", "feedback" and "homework".

2010-10-27T08:13:00.001+01:00

Cognitive Therapy (and other CBT approaches) are well-known for their focus on structure, goal-setting, agenda-setting, homework, practice, reviewing, etc. Indeed, Judith Beck, whose blog I have featured here a couple of times, outlines ten Principles of Cognitive Therapy, at least five of which (3, 4, 6, 7, 8) refer to these areas:

1. Cognitive therapy is based on an ever-evolving formulation of the client and their problems in cognitive terms.

2. Cognitive therapy requires a sound therapeutic alliance.

3. Cognitive therapy emphasises collaboration and active participation.

4. Cognitive therapy is goal oriented and problem focused.

5. Cognitive therapy initially emphasises the present.

6. Cognitive therapy is educative, aims to teach the client to be his or her own therapist, and emphasises relapse prevention.

7. Cognitive therapy aims to be time limited.

8. Cognitive therapy sessions are structured.

9. Cognitive therapy teaches clients to identify, evaluate and respond to their dysfunctional thoughts and beliefs.

10. Cognitive therapy uses a variety of techniques to change thinking, mood and behaviour.

She also provides a recommended structure for the initial session (post-assessment):

Setting agenda

Checking mood

Update on presenting problem

Identifying immediate issues to work on, and setting goals

Educating client about the cognitive model

Eliciting expectations for therapy

Educating client re specific diagnosis

Setting homework

Providing a summary

Inviting feedback

(J. Beck, 1995)

Integrative CBT does believe in the importance of structure, and of processes like homework and feedback which help to provide some structure, but it is not necessary to be as organised as Judith Beck. It can be helpful in some cases to work at the highly-structured end of the continuum (e.g. with very chaotic clients, with children or adolescents, with groups in institutional settings, etc), but Integrative CBT also allows for a more non-directional approach, especially at Levels 1 and 5.

The key issue is continuity, building on gains made, internalising learning. We all know the situation where we have had a really good session with a client one week (lots of insights, changes, hope, etc) only to find that it has completely disappeared the following week, as if the previous session never happened (in fact, sometimes the client seems to have literally forgotten the previous session, even after promptings from the therapist). The idea of therapeutic structure, as I understand it, is to increase the chance of sustaining and building on therapeutic change and learning. Only to increase the chance, I’m afraid - there is no guaranteed way yet (I’m working on it…)

Reviewing progress, getting feedback from the client, revisiting and revising goals – all of these processes should be built into therapy in an ongoing way, not just done occasionally. Most important of all is the concept of “homework” (a word, incidentally, which I try to avoid using with clients, because of the negative, disempowering connotations it has for many people). If clients are to ultimately learn to be their own therapists (see point 6 above), they need to do most of their discovery, practice and experiential relearning out in the world outside the therapy room and in the time outside the therapy hour. In other words, the best collaboration is one where the client does most of the work.

Which brings us to another question: Does the therapy session need to last one hour (or the “50-minute hour”)? Integrative CBT is a pragmatic approach. Its aim is to give the professional help that the client actually needs, where possible - to be, as they say, “fit for purpose”. If a client reaches the stage where they will benefit more from attending for half an hour, in order to update, review and plan, then ideally the therapist should contract for half-hour sessions. Of course, this may not suit the therapist for practical reasons (e.g. scheduling, or the fact that the client is paying less), but that’s another issue. Similarly, there is no therapeutic need for every client to come every week – the crucial test, again, is whether continuity of progress is being achieved. If most of this progress is being achieved outside of therapy, all the better – this is, after all, the goal of therapy.

Reference:

Beck, J. (1995) Cognitive Therapy: Basics and Beyond. New York: Guilford Press.

The Worse it Gets, The Worse it Gets: The Viciousness of Vicious Cycles

2010-10-21T22:30:00.012+01:00

CBT is sometimes thought of as being “just common sense”. While common sense is of course essential in the practice of any form of professional helping, it should be clear from some of the previous blogs that there is much more to CBT than this. Socratic Questioning and Behavioural Experimentation, for instance, are often quite counter-intuitive and are not part of the way we ordinarily think; the same applies to the important idea of Vicious Circle Causality.

The human mind generally tends to think of causality in a linear way, where “one thing leads to another”, and of course this the way things happen a lot of the time. But causal processes can also loop back on themselves, leading to cyclical processes which can become stable and self-sustaining, and may even spiral out of control. We are aware of this, of course, in relation to examples such as “The Snowball Effect” (the bigger the rolling snowball gets the bigger it gets) and “Arms Races” (the more weapons they have, the more we have to have; the more we have, the more they have to have). However, we don’t habitually think of our own mental and behavioural processes in this way (therapists, of course, often use exactly the kind of examples I have just given as metaphors in helping clients to understand some of what is happening in their lives).

This is one of the ideas in CBT which first engaged my interest, and I’ve found it to be a very powerful concept in helping to understand and work with many mental health problems. The idea is not, of course, unique to CBT, but CBT as an approach does put a stronger emphasis than some other approaches on the perpetuating, maintaining factors contributing to a mental health problem along with the predisposing and precipitating factors.

This emphasis is valuable in three main ways:

As a description: Finding the relevant vicious cycles can make sense of the stuckness that a client experiences in relation to their depression, anxiety, anger etc. As I have emphasised previously, the presence of vicious cycles tends to block the experiential re-learning necessary for recovery and growth. Such cycles tend to take on a dynamic of their own, relatively unaffected by other influences such as the environment.

As an explanation: The progressive nature of vicious circular processes can help make sense of how the client developed such a serious problem, especially if there is no obvious major cause in their developmental history. The fact that a major problem does not have to have a major cause is one of the ideas presented here which go against “common sense”.

As a generator of hope: If we understand some of how the problem is being maintained in a circular way, then this may help makes sense of possible ways out; the good news is that positive changes in thinking, behaviour, mood etc are also processed through the cycle, reversing the downward progression and making the cycle no longer vicious (a “virtuous circle”?).

As I described in an earlier blog (25 May), a basic 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 (lack of productive activity reinforces a negative self-view, lack of rewarding activity reinforces low mood, etc).

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.

Here are a couple of examples which I have found to be indispensable:

Panic (Clark, 1986):

The catastrophising misinterpretation (“I’m having a heart attack”) of anxiety symptoms, such as tightness in the chest and heart palpitations, are the crucial element which closes the cycle, leading to further and further increases in anxiety. Reduction in the strength and plausibility of these cognitions (through Psychoeducation, Socratic Questioning, Behavioural Experimentation etc), can completely dissolve the cycle in many cases.

Sexual Addiction (Carnes, 1983):

According to Carnes,

“For sexual addicts an addictive experience progresses through a four-step cycle, which intensifies with each repetition:

1. Preoccupation: The trance or mood wherein the addict’s mind is completely engrossed with thoughts of sex. The mental state creates an obsessive search for sexual stimulation.

2. Ritualization: The addict’s own special routines, which lead up to sexual behaviour. The ritual intensifies the preoccupation, adding arousal and excitement.

3. Compulsive sexual behavior: The actual sexual act, which is the end goal of the preoccupation and ritualization. Sexual addicts are unable to control or stop this behaviour.

4. Despair: The feeling of utter hopelessness addicts have about their behaviour and powerlessness.

The pain the addict feels at the end of the cycle can be numbed or obscured by sexual preoccupation, which re-engages the addiction cycle.”

References:

Carnes, P. J. (1983) Out of the Shadows: Understanding Sexual Addiction. Minneapolis: CompCare.

Clark, D. M. (1986). A Cognitive Approach to Panic Disorder. Behaviour Research and Therapy, 24, 461–70

Social Anxiety: November Conference, and a Blog from Judith Beck.

2010-10-13T07:20:00.001+01:00

I’m putting off the discussion of Vicious Cycles for another week (just building the suspense…).

Instead I’m going to once again feature Judith Beck’s Cognitive Therapy blog from the Huffington Post, this time because it’s on the topic of Social Anxiety. As readers of this blog will know, Social Anxiety is one of my main areas of interest, and I will be involved in a one-day conference on the topic in Dublin on November 28th.

For more information on the conference see this link.

Conference topics will include The Neurobiology of Social Anxiety, CBT for Social Anxiety, Social Anxiety and Alcohol Problems, Groupwork with Social Anxiety, Social Anxiety and Sexual Addictions.

In the meantime, enjoy Judith Beck’s account of her work with a socially anxious client, “Using Socratic Questioning to Help Social Anxiety”, by going to this link.

Being a Worrier: Generalised Anxiety Disorder

2010-10-06T07:45:00.002+01:00

“I am an old man and have known many troubles, but most of them never happened”
- Mark Twain

I’m postponing the blog on Vicious Cycles for another week, because I’ve had the topic of Worry on my mind (because it’s World Mental Health Awareness Week, and anyway there’s no shortage of worry around these days…)

Worry is common and normal - we all worry sometimes. In other words, we anticipate what could go wrong, we imagine a range of possible negative scenarios, we speculate “What if...” in every possible variety. But usually we snap out of it (at least until the next time...)

This is not pleasant, and most of us could probably benefit from doing less of it, but it doesn’t destroy our lives. Some people, however, develop a major worry problem – they become worriers. When does worry become a serious problem?

When worry is compulsive, hard to control, excessive, inappropriate (i.e. usually about minor things), circling around the same anxious predictions again and again, then we have a real mental health issue. This type of compulsive worry is called Generalized Anxiety Disorder (GAD). People with this problem worry excessively about a variety of things (e.g., job, money, family, health), and as the problem develops, more and more of the worry is about hypothetical scenarios, rather than about real challenges. Along with persistent feelings of anxiety, physical symptoms also tend to develop, such as muscle tension, headaches, and difficulty sleeping

4-7% of the population will develop GAD at some point in their lives, women slightly more than men. In terms of remission, GAD symptoms rarely abate naturally over time.

From a Cognitive-Behavioural perspective, GAD has four main features:

1. Intolerance of uncertainty
2. Positive beliefs about worry
3. Negative problem orientation
4. Cognitive avoidance.

1. Intolerance of uncertainty:

Understandably, we mostly worry about things where the outcome is uncertain. Worry is a natural reaction to uncertainty and it can be seen as a way of trying to predict the future and manage the experience of uncertainty. People with a worry problem tend to be especially uncomfortable with uncertainty. Some would even prefer bad things to happen rather than live with the sense of not knowing what will happen next.

However, worrying generates more uncertainty, which in turn fuels more worry.

Behavioural experiments (see last week’s blog) are one Cognitive-Behavioural technique for working to increase tolerance of uncertainty; here the client deliberately does something more uncertain than usual, to test if it is actually as intolerable as they fear, for example:

• Going to see a film they know nothing about
• Going to a different shop for their groceries
• Ordering something they have never had before in a restaurant
• Making opportunities to meet new people
• Breaking routines

2. Positive beliefs about worry:

Compulsive worriers tend to believe that worry helps in some way, though they may not be fully conscious of this. Some common beliefs they may have are:

• Worry finds solutions to problems
• Worry motivates me to do things
• Worry protects me from possible dangers
• Worry prevents possible dangers from happening
• Worry shows I care

Once people become fully aware of these beliefs, they usually begin to see that there is little evidence to support them.

3. Negative problem orientation:

Worriers tend to use unhelpful strategies to try to solve problems, for example:

• Seeking reassurance for decisions (which keeps worry going, as the worrier never learns to trust their own judgement)
• Seeking out excessive information before making a decision
• Making lists as a substitute for actions
• Being overly busy, throwing oneself into activity rather than solving problems (e.g. cleaning)
• Procrastination
• Post-mortem worry: “What if I have made the wrong decision?”

GAD sufferers need to be taught more helpful strategies of problem-solving and decision-making, such as realistic risk-assessment, cost-benefit analysis, trial-and-review, etc.

4. Cognitive avoidance:

Because excessive worry is distressing, many GAD sufferers become worried about their worrying, so they try to go to the other extreme, and push all upsetting ideas out of their mind. This is not a helpful strategy either, as real concerns and issues do need to be faced, and “fearing fear itself” does not improve the situation.

Sufferers are often invited to write down their worries so that they can be faced squarely, and even to set aside a specific “Worry Time” every day, for which they save all their worries. During the specified Worry Time, they are encouraged to worry as hard as they possibly can – this tends to change their relationship with worry as a habit, and can sometimes even be an amusing experience!

Reality-Testing the Beliefs we Live by: Using Behavioural Experiments

2010-09-29T07:50:00.000+01:00

Behavioural Experiments are crucial to working at Level 3 of the Integrative CBT model, and build on Socratic questioning in an ongoing process of guided discovery. Guided discovery (which can also be called collaborative empiricism, trial & review, corrective experience, etc) is the heart of the cognitive-behavioural process of experiential relearning.

Here is one description of the concept of behavioural experiments:

“Behavioural experiments are planned experiential activities, based on experimentation or observation ... Their design is derived directly from a cognitive formulation of the problem, and their primary purpose is to obtain new information which may help to test the validity of ... existing beliefs about themselves, others, and the world...” (Bennett-Levy, J. et al, eds, 2004, Oxford Guide to Behavioural Experiments in Cognitive Therapy. Oxford: OUP – p.8).

Behavioural Experimentation is therefore crucially different from the Behavioural Intervention/Change process which is central to Level 2. Behavioural intervention/change work always focuses 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, meditating, eating more healthily, cutting down on drinking, treating oneself well, etc).

Behavioural experimentation on the other hand might equally focus on “bad” behaviours (e.g. leaving a task unfinished, staying up all night, not being “nice” to everyone, etc), since just as much (or more) can be learned experimentally/experientially from the results of such experiments.

An important related point is that behavioural intervention/change work always focuses directly on central areas in the client’s life that need improvement (e.g. socialising, travelling etc), because the main goal is positive change in the client’s daily behaviour and environment. Behavioural experimentation, on the other hand, often works better if it focuses on areas of the client's life which are less central, but where fruitful experiential relearning is more likely to occur. This is because the stakes are less high in these situations, and new learning is less blocked by negative cognitions and high negative emotions. A behavioural experiment sometimes focuses on something quite small, and it may therefore seem trivial to a client, but it needs to be explained that the main goal is some bit of adaptive change in the client’s cognitions.

Some common examples of behavioural experiments are:

• Asking a depressed client to try drinking a cup of tea more slowly than usual, and with a little more mindfulness. As with all behavioural experiments, it is vital that they first of all make a relevant prediction about this. Here the prediction would be a rating between 1 and 10 as to how much they think they will enjoy drinking the tea. Because of the nature of depressive cognitions, they will nearly always underestimate this, and be pleasantly surprised as a result. This serves both to briefly increase their sense of the potential “rewarding-ness” of their environment, but more crucially it also slightly loosens the grip of their depressive beliefs.

• Suggesting to a socially anxious client that they deliberately make themselves blush (perhaps by agreeing to meet and chat with a colleague of yours for a few minutes). Some socially anxious clients have a range of beliefs about blushing, e.g. “I go as red as a fire engine”, “Everybody notices”, “They think I’m pathetic”. Because they believe these things are true, the last thing they want to do is actually face them and check them out, but this is exactly what is needed. The “fire-engine-red” theory can nowadays easily be tested (and falsified) by the use of video recording and replay.

• Suggesting to a client who suffers from panic attacks, and who believes that they are going to have a heart attack when they experience the tightness in the chest which anxiety brings, that they run up and down the stairs rather than sit down and try to calm themselves. This tests the prediction that they would have had a heart attack if they hadn’t minded themselves carefully, and kept their arousal level low, by deliberately increasing their level of physiological arousal (it is generally advised that they have had a check-up from their GP first, just to rule out genuine heart problems – some dangers are real, occasionally!)

All of this is designed to break down self-perpetuating emotional-cognitive-behavioural Vicious Cycles, which can block out experiential relearning for a lifetime if they are not properly addressed. Behavioural experiments are one great way of doing this, and they can be wonderfully immediate, vibrant and exciting (not to mention scary) for both client and therapist.

More on vicious cycles in next week’s blog...

Don't Believe Everything You Think: The Power of Socratic Questioning

2010-09-22T20:09:00.002+01:00

Integrative CBT case formulation and intervention, while obviously making room for all five levels, are primarily based on the Beck/Ellis theoretical perspective of Level 3, namely that mental health problems are mainly cognitive in their nature and their roots, and are most effectively helped by achieving relevant cognitive change.

This means that we need to help the client get to the cognitive heart of the matter, which is often not all that obvious. In many anxiety problems, for instance, the client is not actually clear what it is precisely that they find threatening. A common example is fear of flying. To be afraid of flying can mean different things: fear of crashing, fear of dying, fear of not being in control (this is one reason why many who fear flying are not nearly so afraid of crashing in their car, even though the latter is much more likely), fear of panicking, of feeling enclosed (so in fact a form of claustrophobia), fear of leaving their children without a parent (this is why many people are more afraid, rather than less afraid, when they are flying in the company of their spouse).

The primary CBT process which is used in this regard is called Socratic Questioning or Socratic Dialogue. This is a cognitive/empathic process which tries to tease out what the client has learnt from their experiences, in other words to help them become clearer about some of their crucial beliefs, which are based on relevant experiential learning. This leads on to a 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. So Socratic Questioning starts out as an exploratory process, and gradually becomes a more challenging, change-oriented process, fostering more functional, adaptive ways of interpreting the important aspects of our lives.

Therapeutic change may take place not just in the content of beliefs, but also in the way they are held, i.e. they may be held more provisionally, more flexibly. In this sense, Socratic Questioning is a philosophical method, an educational method, a part of critical thinking. Its function is to probe & test assumptions, viewpoints, ways of seeing things. It is not just a therapeutic tool; the following list, for instance, has been adapted from Paul, Richard - "Critical Thinking: How to Prepare Students for a Rapidly Changing World" (1993), and yet is very relevant to the therapeutic setting.

• Let me see if I understand you; do you mean _____ or _____?
• Could you give me an example?
• Could you explain that further?
• Do I understand you correctly? You seem to be assuming ____.
• What could we assume instead?
• Why would someone make this assumption?
• Is it always the case?
• Why do you think that is true?
• Do you have any evidence for that?
• What would change your mind?
• What would you say to someone who said ____?
• How could we find out whether that is true?
• Where did you learn this?
• Have you always felt this way?
• When you say ____, are you implying ____?
• Would that necessarily happen or only probably happen?
• You seem to be approaching this issue from ____ perspective.
• What might someone who believed ____ think?
• What would someone who disagrees say?
• What is an alternative way of seeing this?

In the therapeutic setting, this method can lead on to other forms of Guided Discovery, especially Behavioural Experiments (which will be explored in next week’s blog).

The Socratic Method goes back, as the name suggests, to the Ancient Greek philosopher Socrates (who was executed for his persistent questioning of widely-held beliefs), but does not necessarily fully reflect the style and philosophy of the original Socratic dialogues of Plato, which personally I never much took to. But I’ve always been fascinated by the nature of beliefs, where we get them from, why we keep them, why we change them. I love critical thinking, and the process of examining views from every possible angle; and a bit like Socrates, what I’ve discovered personally is that once you start doing this in a committed way, it may lead anywhere...

Sexual Addiction: Integrative CBT Case Formulation, Example 2

2010-09-15T08:13:00.003+01:00

This second example applies the Integrative CBT Case Formulation model to a case example where the main issue is sexual addiction.

Once again, the relevant questions, which follow the 5 Levels of Integrative CBT, are:

How do I best connect with this particular person, and form a therapeutic relationship with them?

What are the immediate problems that need action?

What is the individual psychology/psychopathology of this person? What are their typical cognitive distortions, automatic thoughts, compensatory behaviours, maintaining cycles?

What are the developmental sources of the above difficulties? How does this client see the world, what are their Core Beliefs?

What core human issues are they struggling with?

"Larry" (age 53) came for therapy because his wife had given him an ultimatum. She had found him using Internet pornography yet again, after he had repeatedly promised not to. He was also increasingly neglecting his work as a self-employed architect (there had been less work recently, anyway, so this was also getting him down).

Having been “sent” for therapy because of his “misbehaviour”, Larry was initially mistrustful of therapy and of my role. He was also very ashamed and uncomfortable when it came to talking about the subject of his sexual behaviour. Therefore, the initial therapeutic tasks were to engage with him and form a working alliance, and to project a non-judgmental concern about his situation, normalising it by emphasising its familiarity, while not minimising or justifying. A currently active addiction problem like this may also require a relatively firm and direct stance; the reality of the addictive behaviour and its consequences do need to be discussed openly early on in therapy, as time and options may be running out. For instance, Larry talked about there being other problems in his marriage apart from his pornography use, but we needed to agree to come back to those later.

If negative consequences were reason enough to stop, addiction would not be the problem it is. Ambivalent motivation is central to all addictions (“I wish I wanted to stop, but I actually want to continue to look at porn”), so this would need to be explored with Larry, and some cognizance taken of his current stage on the Wheel of Change (probably somewhere between Pre-contemplation, Contemplation, and Preparation/Determination; see Miller & Rollnick, 2002). The natural negative consequences of continuing the addictive behaviour may need to be revisited here, perhaps in the context of a Cost/Benefit Analysis. With Larry, I would be looking at the threatened loss of his marriage, but also the pain caused to someone he loved, his loss of self-respect, his neglect of his work and other important areas of his life, etc.

As with other disorders, a central reason for the continuation of an addiction, despite the damage it causes, is its Vicious Cycle nature (vicious cycles are central to the Cognitive theory of how psychological disorders are maintained, and will be explored in more detail in a later blog). This insight is at the heart of my own definition of addiction:

A progressively tolerated & progressively damaging

biopsychosocial adaptation to/dependency on

(and therefore preoccupation/obsession with)

the initially intensely mood-altering,

but ultimately only superficially satisfying,

emotional rewards (pleasure and/or pain-relief)

provided by certain artificially-enhanced activities (and their associated rituals),

which require minimal personal investment

(e.g. heroin use, gambling, pornography use, etc)

leading to a self-perpetuating cycle of compulsive behaviours in some of the above areas,

which the addicted person sometimes tries to control, with limited success,

when crisis points are reached

(including the crisis of withdrawal,

but also in response to serious negative consequences

in such areas as health, relationships, finances, employment, legal problems etc),

but which they otherwise resist acknowledging by using

various cognitive-emotional avoidance strategies (distortions/defenses).

A discussion of what it means to be addicted is often essential in this kind of work, and runs through all five levels of Integrative CBT (initial naming of issues, realistic action-planning, cognitive-emotional restructuring, facing underlying issues, understanding addictive human nature). If the addicted client is to make any real progress, their individual rituals, distortions, preoccupations, settings, triggers etc, need to be explored and owned in scrupulous detail. For Larry, some of these would be: being on his own in the house, being stressed and irritable, having the laptop already switched on for other purposes, looking forward to using porn all day, telling himself he deserves it, etc. All of these factors will need to be explored, challenged and changed to some degree in order for Larry to gain freedom from his compulsive behaviour.

It is not always the case that there are underlying dysfunctional core beliefs in cases of sex addiction, but it is certainly common (see Carnes 2001, and my Masters thesis at this link). Typically, we might expect maladaptive schemas in areas such as Abandonment, Shame/Self-hate, Entitlement, Mistrust etc. These are likely to have their roots in such early experiences as family alcoholism, violence or abuse, neglect or bullying. Larry’s story was one of alcoholism in both parents, along with depression in his mother, and bullying from elder siblings. His core beliefs certainly made sense in the light of his early learning experiences.

These areas need to be explored, but may be too delicate to work on until there is some stability in recovery.

Of all the issues that I have worked with, one of the most shameful for many people is Sexual Addiction. This is partly due to its associations with perversion and sexual offending, but also arises from beliefs about the “dirtiness” of sexuality itself (a legacy of many Irish Catholic childhoods).

Understanding and humanising the behaviours, thoughts and feelings involved in sexual addiction is not the same as giving permission for the damaging behaviours. But, unless Larry is helped to understand how his addiction has its roots in the nature of human (male) sexuality, his recovery may remain lacking in self-acceptance and humanity.

References

Carnes, P. J. (2001) Facing the Shadow: Starting Sexual & Relationship Recovery. Wickenburg, AZ: Gentle Path Press

Miller, W. R. & Rollnick, S. (2002) Motivational Interviewing: Preparing People for Change. New York: Guilford.

Depression: Integrative CBT Case Formulation, Example 1

2010-09-08T19:54:00.003+01:00

In this week’s blog, I’m applying the questions outlined in last week’s blog to a case example involving depression. These questions, which follow the 5 Levels of Integrative CBT, are:

1. How do I best connect with this particular person, and form a therapeutic relationship with them?

2. What are the immediate problems that need action?

3. What is the individual psychology/psychopathology of this person?
What are their typical cognitive distortions, automatic thoughts, compensatory behaviours?
What is the inner logic of their irrational problems?
What are the relevant emotional and physiological factors, and maintaining cycles?

4. What are the developmental sources of the above difficulties?
How does this client see the world, what are their Core Beliefs?
What has been their relevant experiential learning?

5. What core human issues are they struggling with?

"Jane", aged 37, has been struggling to cope ever since she was promoted to a higher level of responsibility in her job a year ago. She has had growing difficulty getting up in the morning, her appetite and sleep are poor, and she is increasingly neglecting both work tasks and leisure activities.

1
Jane comes across as emotionally flat, makes little eye contact, and says she has little hope that therapy will help her, therefore extra effort in terms of warmth and positivity is needed by the therapist to connect and to encourage. The therapist may also need to take care not to become overly influenced by Jane’s negative outlook, so that they can retain a hopeful outlook themselves in relation to the therapy.
Her global hopeless thinking may also require a gentle exploration in relation to possible suicidality.

2
Jane has been referred by her GP, who has also suggested that she try anti-depressants. Jane is unsure how she feels about this, or how to come to a decision, so this needs some discussion in terms of accurate information, pros and cons, how we might monitor and review either decision, etc. Other immediate issues, such as who she might tell about her situation, also need to be looked at.

3
The pattern of Jane’s depression will of course be both classic and individual. We expect Negative Automatic Thoughts about herself, her world and her future, and we need to find out what her own specific ruminations and self-talk in these areas are. We would expect themes such as: “I can’t cope with this”, “There’s no point in my trying”, I’m useless”, etc.
She also clearly has avoidance behaviours, which makes sense from her point of view, since her life is likely to seem both unrewarding and anxiety-provoking. Again these need to be teased out on an individual level, and the vicious cycles between her thoughts, behaviours and emotions made clearer and more visible.
This part of the case formulation will suggest where some of the most immediate interventions need to take place, in order to increase the client’s level of functioning, and to provide them with the skills to do this for themselves in the future. In Jane’s case, some of the classic CBT techniques would probably be helpful, e.g.: gradual increase in non-threatening, mildly rewarding behaviours such as going for a walk; monitoring of negative ruminations, so as to at least gain some distance from them, and possibly even test them for validity (more recent techniques such as Mindfulness practice could also be a useful addition here).

4
Beck’ theory of depression contends that amongst the sources of an individual’s vulnerability to depression we will find Cognitive Vulnerability. A detailed exploration of this aspect of Jane’s formulation may need to wait until later in therapy, when she is more able for it (and when relapse prevention is becoming the main focus), but an initial history-taking may well suggest some relevant early experiences and subsequent belief-formation, such as a belief in her own fundamental incompetence. As it happens, she describes a mother who both was and is highly critical, especially of Jane as the eldest in the family. Feeling that she wasn’t good enough, and couldn’t get anything right, has been a familiar experience for Jane throughout her life.

5
Given that Jane is highly critical of herself, she is likely to be highly critical of the fact that she is suffering from depression, and this turns out to indeed be the case. She sees being depressed as “weak” and “pathetic”. This is an attitude which needs to be taken into account by the therapist at all the other levels of work. It will influence the therapist’s efforts
- to form a functioning therapeutic relationship
- to facilitate the making of important practical decisions in areas such as seeking support
- to tease out with the client their individual vicious cycles and underlying belief structures.
This is why it may be important to explicitly discuss this issue at this fundamental level, in an effort to set depression in a more acceptable, human context. I would tend to do this at quite an early stage of therapy, if it seems necessary, by discussing the nature of depression with the client, including its prevalence as a response to ongoing stress and challenge, and its possible evolved function as a form of psychological “retreat”.
The Integrative CBT case formulation can also hold open the possibility of returning to these issues later, if the client wants to try to put a larger spiritual/philosophical perspective on their depression and recovery. Jane, as it happens, is quite a spiritually-oriented person, and may well want to put some meaning on her painful and disruptive experiences in retrospect.

Next week’s blog will look at another case formulation example, with a sexually-addicted male client.

I Love it when a Plan Comes Together: Case Formulation in Integrative CBT

2010-09-01T08:28:00.000+01:00

Case Formulation in Counselling/Psychotherapy can be seen as consisting of

(a) a hypothesis, or set of hypotheses, concerning the sources and maintaining factors of the client’s presenting psychological problem(s)
(b) a plan, based on the above hypotheses, as to when, where and how to intervene, with a view to bringing about some reduction in the client’s problems.

The Case Formulation process therefore guides and structures the course of treatment by unifying and prioritising symptoms, influencing the choice and timing of interventions, and predicting possible difficulties. It should be an ongoing process, open to modification at any stage.

This process is not carried out explicitly in all forms of counselling/therapy, though presumably all therapeutic intervention must be based on some such hypothesising and planning, even if it remains largely implicit. Carl Rogers considered that “a diagnosis of the psychological dynamics is not only unnecessary but in some ways is detrimental or unwise” (1951, p. 223). He was concerned that the process of making a diagnosis leads to an inequality in the power dynamic between counsellor and client. Similar concerns are part of Integrative CBT (at Level 1), but I believe that a collaborative approach to arriving at a formulation should resolve this difficulty. In practice, this means that the therapist presents his own formulations to the client as hypotheses for discussion, and also helps the client to formulate his own hypotheses through guided discovery (J. Beck, 1995). The client should have as full as possible an understanding of what is happening in their own treatment. As Persons remarks (1989, p. 48), ‘If the formulation is so helpful to the therapist, we might also expect it to be helpful to the patient in understanding and managing his behaviour.’

In Integrative CBT, developing the hypothesis is an explicit process, and is part of the work that we do at Levels 3 and 4. Because this is “Integrative Cognitive Behavioural Therapy”, and not just Integrative Psychotherapy in general, the formulation is based on the Cognitive Model of emotional disorders, which “proposes that distorted or dysfunctional thinking (which influences the client’s mood and behaviour) is common to all psychological disturbances” (Judith Beck, 1995, p. 1). As we have seen in earlier blogs, at its simplest level it focuses on Negative Automatic Thoughts which are locked into vicious cycles with dysfunctional emotions, behaviours and physiology. It can also be expanded to include more ongoing dysfunctional underlying cognitions in the form of Assumptions and Core Beliefs.

So the questions an Integrative CBT therapist would be asking themselves about any client would be:

1. How do I best connect with this particular person, and form a therapeutic relationship with them?

There are some general principles here, of course, but also individual differences in how we need to adjust to different clients. Our initial therapeutic engagement will be based on initial impressions, but this can be adjusted in line with whatever emerges at the next levels of exploration. For example, a currently active addiction problem may require a firmer and more directive stance; hopeless thinking may require a gentle exploration of possible suicidality; mistrust and abandonment schemas may require reassurance and clearer discussion of contractual boundaries.

2. What are the immediate problems that need action?

Often the client and therapist agree to work on the most urgent problems, i.e. the most damaging ones, first. But there are also other possible criteria for prioritising problems, such as the likelihood of achieving reasonably quick progress (thereby raising hope and increasing motivation). And new priority issues may emerge as therapeutic exploration continues, especially at Levels 3 and 4.

3. What is the individual psychology/psychopathology of this person?
What are their typical cognitive distortions, automatic thoughts, compensatory behaviours?
What is the inner logic of their irrational problems?
What are the relevant emotional and physiological factors, and maintaining cycles?

Sometimes the pattern which emerges fits well into an existing diagnostic category such as Social Anxiety (see e.g. the Case Example blog from 30 June); in other cases it is a more idiosyncratic mix. But this distinction is a continuum, not a dichotomy – there is always an individual aspect to the most textbook diagnosis, and familiar patterns in the most idiosyncratic psychopathology.

4. What are the developmental sources of the above difficulties?
How does this client see the world, what are their Core Beliefs?
What has been their relevant experiential learning?

This is a crucial piece – it can help clients enormously to see that their problems, and dysfunctional strategies, can actually make sense in the light of their underlying beliefs, and that these beliefs in turn can make sense in the light of their core learning experiences.

5. What core human issues are they struggling with?

It can also be helpful for both client and therapist if problems are seen in their larger human context. Social Anxiety problems, for instance, can be seen as understandably arising in relation to such central human concerns as Status, Belonging, Community, Reputation etc.

As mentioned above, the formulation which emerges at these later levels may in turn influence the style and focus of our work at Levels 1 and 2.

What I have described at levels 2, 3 and 4 are classic Cognitive Case Formulation; 1 and 5 are essential to any good therapy work, whether Cognitive-Behavioural, Humanistic or Psychodynamic. I believe that only Integrative CBT Case Formulation clearly combines them all.

Next week, some I plan to discuss some case examples from an Integrative CBT Case Formulation viewpoint, which hopefully will make everything clear...!

References

Beck, J. (1995) Cognitive Therapy: Basics and Beyond. New York: Guilford Press.

Persons, J.B. (1989) Cognitive Therapy in Practice: A Case Formulation Approach. New York: W.W. Norton.

Rogers, C.R. (1951) Client-centered Therapy. Boston

Holiday Reading (not!)

2010-07-28T07:41:00.000+01:00

I’m signing off for holidays now – the next blog will be at the start of September.

In the meantime, as a partial follow-up to my comments on training last week, here are some books that I have found interesting and helpful in relation to the Integrative CBT approach.

These choices are personal, eclectic, and of the moment... some of them will be very familiar, others not. I’ll let you do your own googling if you want to find out more about any of them.

Level 1:

Clarkson, P. (2004) Gestalt Counselling in Action. London: Sage.

Gilbert, P. & Leahy, R.L. (2009) The Therapeutic Relationship in the Cognitive Behavioral Psychotherapies. Routledge.

Power, M. (2010) Emotion-Focused Cognitive Therapy. West Sussex: Wiley-Blackwell.

Rogers, C.R. (1951) Client-Centered Therapy. Boston: Houghton Mifflin.

Safran, J. & Segal, Z. (1996) Interpersonal Process in Cognitive Therapy. Jason Aronson

Level 2:

Egan, G. (1994) The Skilled Helper: a Problem-management Approach to Helping.
5th edn. Pacific Grove: Brooks/Cole.

Glasser, W.R. (1999) Choice Theory: A New Psychology of Personal Freedom. HarperCollins.

Miller, W. R. & Rollnick, S. (2002) Motivational Interviewing: Preparing People for Change. New York: Guilford.

Nelson-Jones, R. (2006) Human Relationship Skills. Routledge.

Rosenberg, M.B. (2003) Nonviolent Communication: A Language of Life. Puddle Dancer Press.

Level 3:

Beck, A.T. (1976) Cognitive Therapy and the Emotional Disorders. New York:
International Universities Press.

Beck, J. (1995) Cognitive Therapy: Basics and Beyond. New York: Guilford Press.

Bennett-Levy, J. et al (eds) (2004) Oxford Guide to Behavioural Experiments in Cognitive Therapy. Oxford: OUP.

Kouimtsidis, C. et al (2007) Cognitive Behavioural Therapy in the Treatment of Addiction. Chichester: Wiley.

Kuyken, W., Padesky, C.A. & Dudley, R. (2009) Collaborative Case Conceptualization: Working Effectively with Clients in Cognitive Behavioural Therapy. New York: Guilford Press.

Sanders, D. & Wills, F. (2005) Cognitive Therapy: An Introduction. London: Sage.

Level 4:

Young, J.E., Klosko, J.S., & Weishaar, M. (2003). Schema Therapy: A Practitioner's Guide. Guilford Publications: New York

Harris, J.R. (1999) The Nurture Assumption. Bloomsbury Publishing.

Ridley, M. (2004) Nature via Nurture: Genes, Experience & What Makes Us Human. Harper Perrenial.

Bradshaw, J. (1991) Homecoming: Reclaiming and Championing Your Inner Child. Piatkus Books.

Fennell, M. (2009) Overcoming Low Self-Esteem: A Self-Help Guide Using Cognitive-Behavioural Techniques. London: Robinson

Level 5:

Buss, D. (2003) The Evolution of Desire: Strategies of Human Mating. New York: Basic Books.

Feltham, C. (2007) What’s Wrong with Us? – The Anthropology Thesis. West Sussex: John Wiley & Sons

Frankl, V.E. (1997) Man’s Search for Meaning – revised and updated. Simon & Schuster.

Gilbert, P. & Bailey, K.G. (2000) Genes on the Couch: Explorations in Evolutionary Psychotherapy. Hove: Brunner-Routledge.

Nabakov, V. (2000) Lolita. Penguin Classics.

Solomon, A. (2002) The Noonday Demon: An Anatomy of Depression. London: Vintage.

Tolstoy, L. (2003) Anna Karenina. Penguin Classics.

(And many more fiction classics, old and new – here’s a link to an interesting article from Psychiatric Times on “Why Psychiatrists Should Read the Humanities”)

Bye for now, see you in September…