Tuesday 25 May 2010

Making Friends with Cognitive Restructuring

The central aim of Integrative CBT is cognitive change: change in the way we see things, interpret events, talk to ourselves, pay attention to certain aspects of our environment, put meaning on our lives, etc. This level therefore takes us a step beyond the work of Egan etc, into the specifically cognitive focus at the heart of the model.

There seem to be frequent misunderstandings about this type of work; for those of us who love it, talking about it can sometimes feel like trying to persuade people that they would really like your friend if they only got to know them...

Common misapprehensions range from “Working with cognitions is cold, and is not concerned with emotions” to “Working to change thinking is about persuasion, and is only concerned with getting people to think rationally”. Certainly none of this is true of Beck’s Cognitive Therapy, which is the basis for Integrative CBT.

Focus on cognition can be relatively generic, looking at the way in which we all distort our interpretations of our experience; Ellis’s Rational Emotive Behaviour Therapy and the classic Cognitive Distortions outlined by David Burns are good examples of this. A more individualised 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. Integrative CBT gives attention to all four pieces of this symptom cycle, but is Cognitive-Behavioural in being especially focused on helping the client to make relevant changes in their thinking and in their behaviour, in order to reverse the damaging vicious cycles. Integrative CBT therapists therefore need to be comfortable in working with emotion, behaviour, cognition and physiology. (They also need to be able to work with the roots of these vicious cycles in the client’s past, but I’ll say more about that in next week’s blog).

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. The “Overcoming” series of CBT self-help books published by Robinson are a user-friendly way to get up-to date on some of this work. I will also look more closely at some examples in future blogs.

The key change process at Level 3 is what I call Structured and Facilitated Experiential Relearning, or SAFER – hopefully a memorable name, especially because working with anxiety is a particularly good example. When we are overanxious about something (e.g. essay-writing, attending social occasions), we no longer learn from experience in that area, because the cycle of experiential learning has become blocked (we avoid the situation, discount any successes, interpret our discomfort as a sign of failure, etc). When we do manage to make changes in a vicious cycle like this, we do so through Experiential Relearning – discovering through experience that our fears are not well grounded. Sometimes we are lucky, and this process happens without it being deliberately planned or structured (e.g. we find a subject that really interests us, get involved with a new social activity, etc). But when we are really stuck, this process of change requires more Structured Experiential Relearning; a relevant self-help book may provide sufficient structure for some people, but many people need the process to be professionally Facilitated by a therapist.

At this level of Integrative CBT, as in Cognitive Therapy, the learned habits of thinking and behaviour which keep the problem going can be unlearned and replaced through a process of Guided Discovery, using two very powerful therapeutic tools: Socratic Questioning and Behavioural Experiments. Socratic Questioning starts out as a cognitive/empathic process which tries to tease out what beliefs the client has learnt from their life experiences. This then leads into a probing, testing 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.

Behavioural Experiments are different from the Behavioural Change work we discussed at Level 2. At Level 2 we focus 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, eating more healthily, cutting down on drinking, etc). Behavioural Experimentation, on the other hand, might equally focus on “bad” behaviours (e.g. leaving a task unfinished, not being “nice” to everyone, staying up all night, etc), since just as much, or more, can be learned experientially from the results of such experiments. So Level 2 is about engaging with the environment in order to make changes; Level 3 is about engaging with the environment in order to reality-test and re-learn; the main goal is change in the client’s cognitive interpretations, assumptions etc.

Personally, I love this level of work; it can be very alive, engaging and productive. Consider making friends with it if you haven’t already…

Wednesday 19 May 2010

Choice and Action – Moving to Level 2 and Beyond

When we move into the problem-solving attitude of Level 2, while still remaining grounded in the therapeutic relationship, we are travelling in the company of influential figures such as Gerard Egan (Skilled Helper model) and William Glasser (Choice Theory). Both emphasise the importance of establishing a warm working relationship, but also understand that clients often need us to add a directional, change-oriented focus, with a commitment to planning and behavioural trial-and-review. At this level, we don’t need to reinvent the wheel, but can happily incorporate the work of the above approaches, as well as others such as Motivational Interviewing and Solution Focused Therapy.

One of the key questions used in Choice Theory, for instance, can be a very powerful Level 2 intervention: “Does your present behaviour have a reasonable chance of getting you what you want now, and will it take you in the direction you want to go?”

The Egan model provides useful material on action skills such as:

Divergent thinking

Goal setting

Decision making

Problem solving

Evaluating knowledge of resources

Using knowledge of how behaviour is changed

Using knowledge of how useful behaviour is maintained

The Motivational Interviewing approach focuses on some similar ideas, as well as emphasising the following (conveniently alphabetical) steps:

Giving Advice

Removing Barriers

Providing Choice

Decreasing Desirability

Practicing Empathy

Providing Feedback

Clarifying Goals

Active Helping

Solution Focused Therapy suggests interventions such as looking at previous solutions, posing the Miracle Question, etc.

Finally, skill-training in specific areas can also be a focus at Level 2. Again, there is already an enormous amount of work available to be integrated, from Assertiveness Training, Stress Management, and many other areas.

So, although this level of work is easy enough to understand conceptually, it is very broad, and there is a lot for the practising therapist to learn about. (There is also a lot of material for future blogs, as many of these areas can be gone into in more detail from an Integrative CBT perspective - just thought I should warn you!)

Having drawn attention to the kind of work which takes place at this level, and suggesting where we can look for practical material we can incorporate, I want to say a bit more about the process of choosing what level to focus on at any particular moment in therapy; I am not just describing a theoretical model here, but how I actually work. This choice can be influenced by many factors: the client’s goals, the stage of therapy, the type of issues, the overall case formulation, and maybe also the therapist’s individual style.

It is possible to look the five levels of Integrative CBT as a progression, and over the whole period of therapy with a client this may in fact be accurate. For example, addiction counselling often moves from developing trust and acceptance, to encouraging practical behaviour-change steps, to challenging underlying addictive thinking, to addressing “Inner Child” issues, to fostering some self-acceptance as a flawed human being. But of course the different levels are not really separate; from moment to moment in each session the therapist may be moving between problem-focus, the state of the relationship, the childhood story, reviewing goals and motivations, noticing the client’s cognitive distortions, trying to validate and humanise what is happening, etc.

Yes, it does get more complicated once you try starting to problem-solve with a client, while also keeping an eye on the integrity of the therapeutic relationship; and it gets even more complicated when you add in some cognitive restructuring and developmental exploration. Of course it is easier if you take an approach which concentrates on just one of these – but is that good enough for the client? Well, it depends on the issues. Some clients may just need some problem-solving, skill-learning assistance; they may not even need much attention paid to the therapeutic relationship, just the minimum necessary for a working alliance. On the other hand, clients with specific mental health issues such as OCD or anger problems may need to postpone much of this kind of practical work until they have learnt to think and feel differently about their problems through cognitive-behavioural re-learning at levels 3 and 4; otherwise they may be trying to solve the wrong problems (e.g. their co-workers’ unhygienic habits, their spouse’s high expectations!).

One final point: this level is about action, behaviour change, helping the client to have a more positive influence on their environment. It can therefore be seen as more “directive”, often a controversial term. The therapist should not tell the client what to do with their lives, but sometimes they do need to be quite direct in supporting the client to find the direction they want to move in, and to test out ways of moving in that direction. I’m happy to travel that journey with my clients.

Wednesday 12 May 2010

Exploring Level 1 - The Therapeutic Relationship in Integrative CBT

Integrative CBT is, amongst other things, an attempt on my part to follow in the tradition of Aaron Beck, who saw Cognitive Therapy as “...the integrative therapy…” (Beck, 1991). When it came to the therapeutic relationship, Beck was very definitely of the ‘necessary but not always sufficient’ camp. He emphasised that “The general characteristics of the therapist that facilitate the application of cognitive therapy… include warmth, accurate empathy and genuineness…” (Beck et al., 1979). However, he also believed that “…these characteristics in themselves are necessary but not sufficient to produce optimum therapeutic effect…” (ibid.)

So Integrative CBT believes in introducing Cognitive-Behavioural models and interventions, as necessary, into a well-grounded therapeutic relationship. But what do I mean by a well-grounded therapeutic relationship in the context of Integrative CBT?

Firstly, I agree that all therapy is conveyed through the medium of relationship - even with a CBT self-help book, the reader must feel that they are meeting the author, and can relate to them, including trusting them to have reliable information. (The online therapeutic relationship is also very interesting in its own right, but as it is an important and growing topic, I’ll address it, in relation to Integrative CBT, in a separate blog at a later date).

As soon as the two roles of helper and helpee exist, we are dealing with basic issues such as expectations, goals, rationale, telling the story, assessment etc. Indeed, many of these issues are looked at further in later levels, but they need to get a good start here. Many of us are familiar with the problems caused later on by false starts in any of these areas.

Secondly, the therapeutic relationship needs, of course, to be a very particular type of relationship. From an Integrative CBT point of view this is captured first of all by the “non-specific” factors described in the Person-Centred approach, Gestalt Therapy etc. These factors are based on the importance of making real psychological contact with the client, and include familiar skills such as Attentiveness, Linking and Validation , as well as broader attitudes such as Empathy, Congruence and Unconditional Positive Regard. Some clients may need no more than this experience of contact with another human (for instance, clients with uncomplicated bereavement), but in many cases I would also see the need for the additional factors of Explicit Collaboration, Psycho-Education, Guided Discovery etc. In situations where we are dealing with problems like Social Anxiety or an Eating Disorder, there is a lot of detailed problem-solving, cognitive restructuring, etc to be done at other levels, and the groundwork needs to be laid at the beginning.

One of my favourite things about this type of therapeutic relationship is its explicitness – clients have a reasonably clear idea of what is happening and why.

Another interesting point to mention here is that there is a very strong cognitive component to good empathy, which is often neglected; Guided Discovery is all about jointly discovering how this particular client sees their world – what could be more empathic?

Of course, the starting point is the client’s feelings/emotions, and Beck amongst others has made it very clear that CBT is no exception. “How do you feel about that?” is always one of the most fundamental questions a therapist can ask (and keep asking!)

Integrative CBT believes that forming and maintaining the relationship is not the end of the job - we need to move on to other levels, into territory which goes beyond just relationship, into practical work towards change. But in moving ahead with problem-solving, case-formulating and intervening at other levels, we mustn’t lose the felt connection with the client. If we do, we need to go back and re-establish it.

References, further reading:

Alford, B.A. & Beck, A.T. (1997) The Integrative Power of Cognitive Therapy. Guilford Press.

Beck, A.T. (1991) Cognitive therapy as the integrative therapy. Journal of Psychotherapy Integration, 1, 191-198.

Beck , A.T. et al. (1979) Cognitive Therapy of Depression. Guilford Press.

Gilbert, P. & Leahy, R.L. (2007) The Therapeutic Relationship in the Cognitive Behavioral Psychotherapies. Routledge.

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

Monday 3 May 2010

What is Integrative CBT?

As a counsellor/psychotherapist who had a fairly typically eclectic initial training, I have increasingly specialised in the Cognitive Behavioural approach over more than 20 years of varied experience as a practitioner. CBT currently seems to me to be the most solidly-based psychotherapeutic approach, in both theory and practice. However, I also believe that it is best used in an integrative way, pragmatically incorporating the best of what other approaches have to offer.

I present here a model of Integrative CBT, consisting of five different levels of therapeutic interaction which the therapist may move between, depending on the client’s needs:

Level 1: Therapeutic Relationship

Integrative CBT needs to be first of all grounded in a therapeutic relationship, where skills such as Active Listening, Advanced Empathy etc are used to enable the client to experience the therapeutic benefits of a helping human encounter. Sometimes this is all a client needs: containing, holding, support, validation, a safe space to explore their world and their concerns. For other clients, this working alliance serves as the basis for work at the other levels below.

At this level, much can be learned from Humanistic approaches such as Person-Centred Therapy and Gestalt Therapy.

Level 2: Problem-Solving Action

The next level many clients need, in order to create change in their lives, is the level of problem-clarification and practical action. Here clients can be helped to engage more effectively with their environment by decreasing negative behaviours (e.g. social avoidance, passive/aggressive behaviours) and increasing positive behaviours (e.g. using social supports, asserting oneself). This can be achieved both by introducing them to general principles of change such as goal-setting, planning and reviewing, as well as by introducing specific life-skills training in areas such as stress management, assertiveness, decision-making etc.

A lot of useful material for this level can be found in the Egan Model, Choice Theory, Motivational Interviewing etc.

Level 3: Experiential Re-learning

The next level of intervention which may be needed (especially for those with specific mental health issues such as Depression, OCD, etc) is collaborative, educative Cognitive/Behavioural/Emotional re-learning. This is the heart of CBT, and is based on the work of Beck and Ellis. Here we help the client to untangle self-perpetuating vicious cycles between their Environment, Cognition, Emotion, Behaviour and Physiology, so that they can unlearn what is dysfunctional and learn new, more functional, approaches. This happens through a process I call Structured and Facilitated Experiential Re-learning (SAFER). At this level we use core Cognitive-Behavioural Guided Discovery processes such as Socratic Questioning and Behavioural Experimentation.

Many techniques from other approaches can also be usefully integrated at this level; Mindfulness training is a well-known example.

Level 4: Schema Change

Of course, many clients need longer-term developmental work, involving more detailed life-history exploration and deeper Cognitive/Emotional restructuring at the level of Core Beliefs. This can help clients to gain a broader understanding of the sources of their difficulties, as well as increasing resistance to relapse through lessening the influence of maladaptive Core Beliefs/Schemas.

One approach to this is Jeffrey Young’s Schema Therapy, which is CBT-influenced but also explicitly integrative in its theory and practice, incorporating aspects of Attachment Theory and Object Relations Theory, amongst others.

The equivalent of transference/counter-transference issues can also be explored at this level, within the framework of a Cognitive Behavioural case formulation approach.

Level 5: Coming to Terms with the Human Condition

Since not all difficulties can be resolved through therapy, clients may need help to understand and process the realities of the human condition which necessarily remain. Some of these may be specific to their circumstances and history, or to their particular mental health problems (e.g. long-term health issues, marital separation, wasted career potential, partially-healed trauma). Others arise from the evolved vulnerabilities of our species (e.g. unhealthy appetite for sugar, tendency to fall in love, anxieties regarding status and meaning), or are just part of the essential nature of life (e.g. competition, rejection, risk, loss, old age, death).

Here the therapist tries to help the client towards a greater understanding of themselves as a human being, incorporating whatever perspectives they find helpful, whether philosophical, cultural, scientific, existential, or spiritual.

A relevant approach that has grown out of CBT is Paul Gilbert’s Compassion-Focused Therapy.

Since this level is about humanising the client’s experience, it brings us back full circle to Level 1, where the therapist tries to meet the client non-judgmentally human-to-human.


Over the next few weeks I’ll be expanding on these levels, giving some examples as to their use in practice, then going on to explore various topics relevant to the Integrative CBT approach, such as safety behaviours, vicious circle causality, case formulation, evolutionary theory, and online counselling.

All feedback welcome!