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

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.

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

“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

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

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

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).

1

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.

2

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.

3

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.

4

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.

5

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

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.