Wednesday 30 June 2010

Case example 1, Part 1

I’m going to give a few case examples over the next while, using the 5 levels already described to help illustrate the practice of Integrative CBT. The examples are, of course, fictionalised composites based on my clinical and supervisory experience.

The first example is "Richard", in his mid-thirties, single, a secondary school science teacher. There are obviously many different things going on in the therapy process, so the following are just some strands picked out from the imagined first few sessions, for illustration purposes. Richard came to therapy because he was feeling very depressed and was losing motivation and enjoyment, even for the job he loved. He had gone to his GP, who had prescribed antidepressant medication, but also suggested he try CBT.

Level 1:

Every client needs to first of all tell their story at their own pace, in their own way, and Richard especially so. He was very self-conscious about doing this, and kept saying how badly he was telling it, and how confusing it must be for me. I assured him it was fine whatever way it came out, that I was getting the information I needed, and that I would ask him anything I needed to know.

Despite this reassurance, Richard continued to be visibly anxious and restless during the first few sessions. In fact, he looked more anxious than depressed.

Level 2:

Richard had some immediate concerns which he was anxious to make decisions about:

Should he take sick leave, as his GP was suggesting?

Should he try the medication, or would this interfere with therapy?

Should he tell his parents about his situation, or would that just worry them?

These are questions which may have deep roots (especially the last one), but which also needed to be dealt with at a practical level for now, in order for the therapy to proceed. However, useful responses to them partly depend on a clear, agreed diagnosis, which may or may not match that made by the GP, who typically only has a few minutes with a patient.

Level 3:

As we discussed Richard’s current concerns in more detail, it emerged that what he felt most low about were his interpersonal difficulties. While he had always felt fine teaching in front of a class (until recently), he had never felt comfortable in the staff room, or going out for a drink after work. He had had some friends during his school days, but had been very socially isolated in college, and had remained so since. He lived alone, and his weekends were very lonely – he usually went to visit his parents, but otherwise had little social contact.

When we looked more closely at Richard’s specific cognitions, emotions and behaviours, it became clear that we were not just talking about shyness or lack of social skills. His anxiety was mainly about his belief that people thought of him as “awkward”, “stupid” and “pathetic”, and he tended to avoid much contact when in the staff room, busying himself with work.

This pattern clearly constitutes Social Anxiety (see last week’s blog), and this was very clear to Richard once he had a chance to read about the typical symptoms. Since research has shown that CBT can be very effective with Social Anxiety, we agreed to work on this over a few weeks and see how we got on.

Level 1:

Richard felt that his problems had been really understood for the first time, which strengthened the therapeutic alliance.

Level 2:

This diagnosis also had implications for Richard’s practical concerns above. First of all, it was becoming less clear that the primary diagnosis was actually depression – his gradual descent into low mood, low motivation and hopelessness might well be fully explained by his years of loneliness without hope of change.

We therefore agreed that he might discuss with his GP leaving the medication until he had tried some CBT – if it became necessary, we could look again at the medication option (which doesn’t necessarily interfere with CBT work, but can facilitate it).

It also seemed that sick leave might just feed his sense of isolation, and that therefore it might be best if we worked first on his dread about going into work.

This meant providing training in some basic anxiety management techniques, and suggesting to Richard that he practice them and see how they worked for him in coping with his daily anxieties.

Level 4:

We also discussed a bit about how these problems might have come about, though I explained that the CT approach would involve working on the current maintaining cycles before we would decide whether we needed to do much work on the underlying core beliefs.

However, we at least mapped out the territory at a basic level, identifying that Richard’s critical father and anxious mother, along with his own innate sensitivity, may well have left him with a fear of judgement by others, as well as a lot of doubt about his own ability to connect. More specifically, his main core beliefs could be along the lines of: “Nothing I do is ever good enough”, “people are critical”, “I’m different” etc.

Level 2:

We decided that the question about sharing his problems with others close to him was an important one, but that perhaps his parents were not the best people to start with. The only other person he felt at all close to was his younger sister, and he decided to share just a little of what was going on for him with her.

Level 5:

Gaining some understanding of Social Anxiety as a common human problem, teasing out some of its roots in his development, trusting some professional helpers and one family member with some of his concerns (none of whom reacted with shock or horror), all helped Richard to begin to humanise his painful experiences somewhat, even before much had been done to substantially change what was quite a deeply ingrained pattern.

Continued next week…

Wednesday 23 June 2010

Meet Social Anxiety

Once again, I’m deferring the first case example; one of the issues it will include is Social Anxiety which, despite being a common issue, is not well-known to many practitioners. I'm therefore giving a description of it here, along with some of the standard CBT approach to it, so as to lay the ground for next week’s Integrative CBT perspective on dealing with the complexities of a client presentation.

The DSM-IV criteria for Social Anxiety Disorder/Social Phobia (in summary) are:

A. A persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others.
The individual fears that he or she will act in a way (or show anxiety symptoms) that will be embarrassing and humiliating.

B. Exposure to the feared situation almost invariably provokes anxiety, which may take the form of a Panic Attack.

C. The person recognizes that this fear is unreasonable or excessive.

D. The feared situations are avoided or else are endured with intense anxiety and distress.

E. The avoidance, anxious anticipation, or distress in the feared social or performance situation(s) interferes significantly with the person’s normal routine, occupational (academic) functioning, or social activities or relationships, or there is marked distress about having the phobia.

This is a useful description, though I’m not convinced that it necessarily has to involve unfamiliar people (point A above).

A simpler summary would be that Social Anxiety refers to symptoms such as:

• acute self-consciousness, awkwardness and self-focus
• over-focus on anxiety symptoms such as blushing, shaking and sweating
• frequent embarrassment, feeling different, unwanted and negatively judged.

While we all experience some social anxiety when we are in social situations outside of our comfort zones (e.g. attending a wedding where we know nobody), the extremeness of the above symptoms in some cases, and the huge extent to which they negatively affect some people's lives, are what leads us to diagnose Social Anxiety. For the Socially Anxious person there is a constant fear of being negatively judged – social life is like one long nightmare job interview. They can never fully relax when there are others around, and so often tend to avoid social situations. In some cases there are particular worries and self-consciousness about anxiety symptoms such as blushing, sweating, shaking etc. These may of course be real, but are rarely as bad as the sufferer imagines.

Social Anxiety is not the same as shyness (a shy person may not be very confident in social situations, but they don’t necessarily experience a high level of anxiety around them) or introversion (a personality characteristic – some people just like a lot of time alone). Nor or the Socially Anxious person’s social skills necessarily poor, though they generally fear they are (and they may well be out of practice).

For some people these symptoms are experienced in all social situations, for others just in specific but important ones (e.g. meetings, presentations, speeches). Many sufferers manage to mask and cope with the problem to a certain extent, but only at the cost of quite a lot of damage to their life and happiness: they experience constant high levels of anxiety, and/or impose serious limitations on their social life, relationships, work, education etc).

Unfortunately, some also try to manage their anxiety using alcohol or other drugs, which can eventually lead to an addiction problem.

The loneliness and isolation that is the result of some people’s Social Anxiety problem can lead them to depression and even ultimately to suicide.

CBT for Social Anxiety helps the client explore their tendencies

• To worry and mentally rehearse for hours before social events
• To practice a range of “Safety Behaviours” in social settings (e.g. staying on your own, leaving early, drinking before going out, trying too hard to be “interesting”)
• To carry out a thorough, self-critical, “post mortem” after social events.

Such habits of thinking and behaving are understandable, given the anxiety the sufferer feels, but unfortunately they all tend to further exacerbate and perpetuate the problem. The Cognitive Behavioural Therapist and client work together to change these ingrained habits by identifying habitual thoughts (e.g. 'what if somebody sees me blushing'), beliefs (e.g. “people will think I am weak”), and patterns of thinking (e.g. common cognitive distortions/thought filters such as All or Nothing Thinking, Discounting Positive Feedback, Mind-reading, Emotional Reasoning, and Catastrophising), which can be questioned and tested. Even getting a clear picture of these can take some of their power away. The next step is to reality-test some of these in an experiential way, through planned behavioural experiments (e.g. going to a cafe and observing that not everyone is looking at you). People who believe that they blush “as red as a fire engine” may need to take the step of seeing themselves on video when they are blushing (e.g. when describing an embarrassing moment to the therapist), so that they can see that the reality does not match their fears.

One crucial step is that the socially anxious person must, at some point, begin to drop some of their safety behaviours, and see what happens. This may mean, for example, not preparing what to say in advance, not trying to agree with everyone, not bringing a huge present to a dinner party, etc. They gradually begin to see that not only are people not judging them all the time (only sometimes, and maybe they can survive this!), but that they are not even in other people’s minds most of the time.

Wednesday 16 June 2010

Some Thoughts on Elephants, Integration and Fish…

I’m going to postpone the first case example until next week, and prepare the ground a bit by summarising what I have been saying about Integrative CBT.

The Buddha tells the story of a king who had six blind men gathered together to examine an elephant. When the blind men had each felt a part of the elephant, the king went to each of them and said to each: 'Well, blind man, what sort of thing is an elephant? The blind men assert that the elephant is either like a pot (the blind man who felt the elephant’s head), a wicket basket (ear), a ploughshare (tusk), a plough (trunk), a granary (body), a pillar (foot), a mortar (back), a pestle (tail) or a brush (tip of the tail). The men cannot agree with one another and come to blows over the question of what an elephant really is like...

In a similar way, various psychotherapy schools tend to emphasise different factors which can lead to therapeutic change – awareness (Gestalt Therapy), working with Transference (Psychodynamic Psychotherapy), Cognitive Restructuring (CBT) etc. Each approach has its own idea of what a client most needs. Because no single approach has yet been found to help all clients with all issues in all situations, eclecticism has also gained a strong footing in the psychological therapies, along with attempts to achieve a more integrated approach. My experience is that clients need us to be able to work flexibly at a variety of levels, hence my attempt at a more integrative approach.

To be genuinely integrative, rather than just eclectic, an approach needs to be based on a core theory of therapeutic change. Following Beck, the core change in successful Integrative CBT is understood to be cognitive change. While this change may need to be facilitated by the direct cognitive restructuring techniques of traditional CBT (Level 3 Integrative CBT), it equally may require a containing relationship (Level 1), problem-solving tools and direction (Level 2), developmental exploration, including at a transferential level (Level 4), and some attempt to set problems and recovery within the context of the human condition (Level 5). A case is therefore formulated in primarily cognitive terms (i.e. beliefs and other cognitions are seen as the main determiners of emotions, behaviours etc), but the primary work may be at any or all of the five levels described. This clearly involves a wide skill-set, if the therapist is to be flexible enough to meet a client at any of these levels.

One last point on why this particular integration is built around CBT (leaving aside the fact that it has a stronger scientific basis in both theory and research):
The idea of ongoing work by the client in between sessions (often unfortunately called ‘homework’) is a key aspect of what makes this approach effective. Remember, this is all about experiential re-learning, which needs to take place outside the therapy room at least as much as within it (probably more so). So skills practice, recording of thoughts, behavioural experiments etc are just ways of continuing the therapeutic work in the time between sessions, and often in the settings where it is most relevant. To get this sort of continuity, and some cumulative therapeutic benefit, is not easy. In fact, it is one of the greatest challenges in therapy. But it is also one of the greatest gifts we can give to a client. You know the story about giving a man a fish, versus giving him a fishing rod and teaching him to fish...

I started with an elephant, now I’m on to fish...better sign off for now!

Wednesday 9 June 2010

Level 5: Only Human

In the unlikely event that a client was completely ‘sorted out’ through therapeutic work at the first four levels (their lifestyle fully balanced, all their irrational anxieties lifted and maladaptive schemas healed!) there would still be serious issues facing them, because that is part of the condition of being human – all the more so, in realistic cases. Dealing with this aspect of therapy is the last level that needs attention to complete the Integrative CBT model.

Focusing on what it means to be human is of importance to the therapy process in at least three ways. First of all, it can help the client to more deeply understand their vulnerability to the problems they have grappled with; not just why they are individually vulnerable to depression, or addiction, or relationship difficulties, but why human beings in general are vulnerable. This can be a great help with the process of normalising and de-stigmatising problems, and developing self-compassion. It can also help clients put their struggles in a broader context, giving them some meaning.

The challenges of being a human are unavoidable in many different ways. As with any organism, we are exposed to risk, loss, old age, and death. More specifically, it is in the instinctive nature of the human species to have an unhealthy appetite for sugar, fat and salt, to experience ongoing anxieties regarding status and resources, and so on. The challenges of life may also vary with gender, age, and environment, as well as within different cultures and subcultures.

I think putting some focus on the nature of human nature is of particular importance in therapy, and I will say a little bit more about it below. For now, let’s just say that it may be important for clients to know that ordinary, non-pathological, humans sometimes feel sorry for themselves, are sometimes angry with people they care about, sometimes think life might be pointless, are sometimes attracted to people other than their partner, sometimes fantasise about being violent, sometimes shout at their children, sometimes worry about the future…

Secondly, focusing on the human level can help the therapist and client with the task of planning for the client’s future in a pragmatic way, based on a realistic view of what it is to be a human facing the particular circumstances this client is facing. Not everything is possible for everyone, and limits are set by factors such as age, resources, previous choices, personality and values. The fact that therapeutic planning happens within limits isn't necessarily bad news. Working within limits is where the creative action is; ask any artist or composer – or any recovering alcoholic.

Thirdly, some view of what it is to be human is implicit in every approach to psychotherapy, and should be made as explicit as possible. A view of the human condition is not just something that we come to at the end of therapy, but a theme that runs right through the process, and influences what both client and therapist believe to be possible. The personal philosophies of being human which can be found amongst clients and therapists obviously vary enormously, from new age to existential to scientific to religious fundamentalist etc. My own assumptions are already showing in the first sentence of this week’s blog: I’m obviously assuming that complete healing is not possible, or at least extremely unlikely - I see this as realistic, some might see it as pessimistic!

Along with this, there are the formal psychological theories of human nature on which any therapeutic approach is based, for example the optimistic, growth-oriented perspective of the Humanistic approaches, the relatively pessimistic Freudian view, or the pragmatic, scientific model of most Cognitive-Behavioural schools.

Since the role of the therapist is to help the client towards a greater understanding of themselves as a human being, incorporating whatever philosophical, cultural, scientific, existential, or spiritual perspectives the client finds helpful, the best that can be done is to discuss these issues explicitly at appropriate points in therapy (by raising the question of long-term goals, values, etc). Client and therapist do not have to fully agree, though too great a difference in views may simply not work for the client (especially in relation to value-laden issues such as abortion, pornography, etc).

My own preference is to incorporate the evidence-based findings about human mental health provided by psychological science. Since clients are coming to me partly for professional expertise in just such areas, this seems appropriate. For instance, I find it useful to educate the client a bit about Evolutionary Psychology, especially when working with anxiety problems (by explaining that anxiety has a function, that it evolved for a reason, that it doesn’t always work well in modern environments, etc), as this helps to humanise problems, making expectations more realistic.

One writer who is very good on this compassionate humanising of experience, especially in relation to shame and self-criticism, is Paul Gilbert, author of Overcoming Depression, and various books on Compassion-Focused Therapy, etc. See this link for one of his articles.

In next week’s blog, I will be outlining a first case example in order to give a bit more of a flavour of how Integrative CBT can work in practice.

Wednesday 2 June 2010

A Client with a Past: Schema-based Case Formulation

Therapists who are dismayed at the lack of any detailed exploration of the client’s past, and especially their early development, in cognitive-behavioural approaches such as REBT and Choice Theory, will hopefully be relieved to know that Integrative CBT sees such an exploration as essential, though it may or may not need to be a central focus of therapy, depending on the client’s issues and goals.

Even when the focus is mainly at other levels, therapeutic choices are best guided by a broad Case Formulation (more on this in future blogs). Working at Level 4 involves adding a developmental perspective to the vicious cycles discussed in the previous blog, expanding the formulation to include hypotheses about the client’s underlying dysfunctional cognitions (see e.g. Persons, Padesky). 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 (blocking experiential re-learning at an even deeper level than that discussed in the previous blog). These templates can be called Schemas; their contents (e.g. “I’m unlovable”, “Men can’t be trusted” etc) can be called Core Beliefs.

Persons suggests that this kind of formulation can explain how current problems are precipitated, and how they actually make sense in the light of underlying schemas and current triggers. It can also suggest origins of the underlying beliefs in the client’s early life. A typical diagram for a Schema-based case formulation is shown below.

Negative Automatic Thoughts are seen as arising, in relevant trigger situations, from underlying Schemas/Core Beliefs. For instance, a depressed client’s negative automatic thoughts could arise out of underlying beliefs such as ‘I’m no good’ and ‘If I try anything, I make a mess of it’, triggered by some current situation which is seen as a failure (e.g. applying for a job and not being called for an interview). These beliefs could be rooted in the client’s early experiences of being treated as no good, or being told that he was no good.

A useful addition to the general concept of Schemas is Jeffrey Young’s proposed set of 18 Early Maladaptive Schemas. They are grouped within 5 domains, each referring to a core childhood developmental need, as follows:

Disconnection/Rejection: Emotional Deprivation, Abandonment, Mistrust/Abuse, Social Isolation/Alienation and Defectiveness/Shame.

Impaired Autonomy/performance: Failure to Achieve, Functional Dependence/Incompetence, Vulnerability to Harm/Illness and Enmeshment/Undeveloped Self.

Other Directedness: Subjugation, Self-Sacrifice and Approval-Seeking.

Overvigilance/Inhibition: Emotional Inhibition, Unrelenting Standards, Punitiveness and Pessimism.

Impaired Limits: Entitlement and Insufficient Self-Control/Self-Discipline.

These Schemas can be explored with clients through the use of handouts which describe each schema in more detail, as well as by using the Young Schema Questionnaire (more information at Many clients find it reassuring to realise that their underlying patterns of thinking are not unique, but human and well-known.

Young’s Schema Therapy is one approach to working with the deeper level of Cognitive/Emotional restructuring which is needed here. He proposes that we continue to use the traditional CBT interventions of Socratic Dialogue and Behavioural Experimentation, as described in the previous blog, though he emphasises that the process of change is likely to be slower when working at the Schema level. He also incorporates techniques such as guided imagery, and adds some other interesting therapeutic strategies, especially Limited Re-parenting.

This level of work allows a lot of room for overlap and integration with theoretical constructs from other schools, such as Models of Attachment, Transactional Analysis Scripts, Object Relations, Conditions of Worth, etc. Integrative CBT uses primarily CBT language, partly for theoretical consistency (not just with CBT, but also with the Cognitive Sciences of Psychology, Neurology etc), but also because this language has become quite accessible to clients through its use in self-help books, where terms such as “Core Beliefs” are now commonly used, along with equivalent terms such as “Bottom Line”. This accessibility is important, because the case formulation process should be shared with the client. Many clients find the notion of particular beliefs acting as a link between their past experiences and their present difficulties to be an illuminating one, and it may even help them to have more compassion for themselves in their struggle with difficult issues such as depression or addiction.

Tune in to next week’s blog, when compassion will once again get a mention…