Self-care break in blogging until the New Year

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

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.

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".

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.