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…


  1. Hi Eoin, very interesting piece again well done! On reading it I was wondering if you have any opinions on what makes someone suitable for CBT or not. It's just that I have heard people say that they have been refused CBT on the basis that they were not suitable and often wonder why this might be...you may not be able to answer that one but I just thought I would throw it out there. Do you think it might be different in private practice as opposed to going to a public service? Maybe in private practice there is a bit more flexibility in how we integrate it which I think is important. Be interested in anybody's thoughts on this one. Anne

  2. Hi Anne

    There are various views on client suitability for CBT. Judith Beck emphasises ability to recognise and discuss emotions, which is probably relevant to all psychotherapy. A certain level of stability may also be needed to engage in any psychotherapy (for instance, the chronic heroin addict may not benefit very much). More specific to CBT, perhaps, would be the client's willingness to collaborate in developing their own psychological awareness (emotions, thoughts, behaviours etc and their connections).

    I definitely agree that the situation is different in private practice. In publicly-funded services, a specific programme of treatment often needs to be followed for a particular disorder, and not every client fits neatly into this system.

    It's an interesting question - certainly, part of the idea of Integrative CBT is that it can include both short-term, manualised, disorder-specific work, along with more flexible, longer-term, multi-level, individualised work.


  3. Hi Eoin,
    Thanks for responding, it is an interesting one and it is one that I keep debating. I agree with a lot of what you have said in regards the ability to recognise and discuss emotions, a level of stability and that willingness to collaborate in developing psychological awareness.

    You mention the heroine addict as an example in this case that they may not benefit and I would agree - you tend to meet the substance rather than the person. However I think that sometimes the trust in the relationship takes times to build, I believe that this is something that generally happens within therapy but for some clients it may take more time, consider clients who have suffered ongoing abuse - they may have learned to detach from their feelings as a kind of defense mechanism - this doesn't mean longterm that they would not benefit from some of the CBT skills but it may take time to build up to that point. Yes I would agree with you that it is very different in private practice and it might be interesting to do some research on it. It seems that up to now research seems to be based on the people who are suitable for CBT, so the results may lean towards a positive outcome which is great in one way but not very accurate in another. There are people who need to work more slowly and at times it seems that CBT can be seen as the only reputable approach which gives the "quick fix", you have learned the skills and now it's up to you - that I feel can actually work against clients when they struggle, I also believe it can actually lower self-esteem because they feel that they have even failed at this - so I think the Integrative Approach and an openess to how it is used is extremely important. Anne

  4. Yes, Anne, I agree that when a client's problems are complex it can definitely lower their self-esteem if they have unrealistic expectations (perhaps from whoever referred them, or from something they read) that they should be able to make significant changes quickly. It can also be hard on the self-esteem of the therapist!

    Hopefully a more integrative way of looking at CBT may help...

    Now we just need to do that research!

  5. Hadn't thought of the self-esteem of the therapist but yes you are right...

    Can't believe I suggested researching something but it would be a very interesting piece of work to do.