Wednesday 28 July 2010

Holiday Reading (not!)

I’m signing off for holidays now – the next blog will be at the start of September.

In the meantime, as a partial follow-up to my comments on training last week, here are some books that I have found interesting and helpful in relation to the Integrative CBT approach.

These choices are personal, eclectic, and of the moment... some of them will be very familiar, others not. I’ll let you do your own googling if you want to find out more about any of them.

Level 1:

Clarkson, P. (2004) Gestalt Counselling in Action. London: Sage.

Gilbert, P. & Leahy, R.L. (2009) The Therapeutic Relationship in the Cognitive Behavioral Psychotherapies. Routledge.

Power, M. (2010) Emotion-Focused Cognitive Therapy. West Sussex: Wiley-Blackwell.

Rogers, C.R. (1951) Client-Centered Therapy. Boston: Houghton Mifflin.

Safran, J. & Segal, Z. (1996) Interpersonal Process in Cognitive Therapy. Jason Aronson

Level 2:

Egan, G. (1994) The Skilled Helper: a Problem-management Approach to Helping.
5th edn. Pacific Grove: Brooks/Cole.

Glasser, W.R. (1999) Choice Theory: A New Psychology of Personal Freedom. HarperCollins.

Miller, W. R. & Rollnick, S. (2002) Motivational Interviewing: Preparing People for Change. New York: Guilford.

Nelson-Jones, R. (2006) Human Relationship Skills. Routledge.

Rosenberg, M.B. (2003) Nonviolent Communication: A Language of Life. Puddle Dancer Press.

Level 3:

Beck, A.T. (1976) Cognitive Therapy and the Emotional Disorders. New York:
International Universities Press.

Beck, J. (1995) Cognitive Therapy: Basics and Beyond. New York: Guilford Press.

Bennett-Levy, J. et al (eds) (2004) Oxford Guide to Behavioural Experiments in Cognitive Therapy. Oxford: OUP.

Kouimtsidis, C. et al (2007) Cognitive Behavioural Therapy in the Treatment of Addiction. Chichester: Wiley.

Kuyken, W., Padesky, C.A. & Dudley, R. (2009) Collaborative Case Conceptualization: Working Effectively with Clients in Cognitive Behavioural Therapy. New York: Guilford Press.

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

Level 4:

Young, J.E., Klosko, J.S., & Weishaar, M. (2003). Schema Therapy: A Practitioner's Guide. Guilford Publications: New York

Harris, J.R. (1999) The Nurture Assumption. Bloomsbury Publishing.

Ridley, M. (2004) Nature via Nurture: Genes, Experience & What Makes Us Human. Harper Perrenial.

Bradshaw, J. (1991) Homecoming: Reclaiming and Championing Your Inner Child. Piatkus Books.

Fennell, M. (2009) Overcoming Low Self-Esteem: A Self-Help Guide Using Cognitive-Behavioural Techniques. London: Robinson

Level 5:

Buss, D. (2003) The Evolution of Desire: Strategies of Human Mating. New York: Basic Books.

Feltham, C. (2007) What’s Wrong with Us? – The Anthropology Thesis. West Sussex: John Wiley & Sons

Frankl, V.E. (1997) Man’s Search for Meaning – revised and updated. Simon & Schuster.

Gilbert, P. & Bailey, K.G. (2000) Genes on the Couch: Explorations in Evolutionary Psychotherapy. Hove: Brunner-Routledge.

Nabakov, V. (2000) Lolita. Penguin Classics.

Solomon, A. (2002) The Noonday Demon: An Anatomy of Depression. London: Vintage.

Tolstoy, L. (2003) Anna Karenina. Penguin Classics.

(And many more fiction classics, old and new – here’s a link to an interesting article from Psychiatric Times on “Why Psychiatrists Should Read the Humanities”)

Bye for now, see you in September…

Wednesday 21 July 2010

Choosing from the Integrative CBT Menu

This week’s blog comes to you from Manchester University, where this year’s annual conference of the British Association for Behavioural & Cognitive Psychotherapies is being held, so I’m surrounded by CBT...

In this blog, the second-last one before I break for August, I want to say a bit more about how to make use of the ideas of Integrative CBT. In future blogs, I will explore Cognitive Case Formulation further, as this is the essential tool which guides the choice of interventions. In the meantime, Integrative CBT can also be seen as offering a menu of interventions to choose from, based on therapist style, preference and orientation, as well as on the client’s preference, the main issues/problems, and the stage of therapy. Many therapists will identify more with one level than with the others; this is fine, and is presumably based on training, personality, type of client issues, etc. From a theoretical viewpoint, however, the Integrative CBT model is based centrally around the Cognitive/Emotional focus of Level 3. This is based on sound scientific principles and research findings. However, therapy, especially with complex clients, is also an art, with an element of creativity needed – perhaps I should be using the metaphor of the palette rather than the menu...

The elements I have listed here may fall into various categories such as attitudes, skills, techniques, strategies, change factors, etc. Some are found at more than one level; for example, I have put Immediacy in at Levels 3 and 5, and it could probably be seen as relevant at other levels also. Some are more relevant to the therapist, some to the client. Please feel free to add to the list...

Level 1: Therapeutic Relationship




Active Listening, including non-verbal


Paraphrasing, summarising

Prompting, evoking


Using Advanced Empathy

Containing, Supporting

Accepting, Validating, Encouraging

Use of self, Contact, Congruence

Using silence

Providing the client with a rationale

Assessment, Diagnosis

Getting feedback from the client

Level 2: Problem-Solving Action




Prioritising, establishing an agenda

Planning, Committing, Reviewing and Evaluating

Specific life-skills training in areas such as Stress Management, Assertiveness etc

Giving advice, information, suggestions, recommendations

Exploring choices

Decreasing desirability of damaging options

Developing discrepancy, confronting

Providing feedback

Active helping

Supporting self-efficacy

Looking at previous solutions

Posing the Miracle Question

Level 3: Experiential Re-learning

Use of inventories, ratings

Diagnosis-specific Case Formulation

Untangling self-perpetuating vicious cycles


Identifying emotions

Staying with emotions

Socratic Questioning

Identifying cognitive distortions

Evaluating Evidence

Behavioural Experimentation

Continuum thinking

Cost/benefit analysis

Discovering alternative thoughts

Mindfulness training

Changing language


Formulating and testing concrete hypotheses

Level 4: Schema Change

Detailed life-history exploration

Identifying key schemas, core beliefs

Deeper Cognitive/Emotional restructuring

Exploring Transference/counter-transference issues


Individualised, longitudinal, developmental Case Formulation

Imagery, visualisation




Art therapy

Inner Child work

Psychodrama, Role Play, Modelling

Empty Chair work

Symbolic Letter

Level 5: Coming to Terms with the Human Condition

Exploring what it means to be human

Exploring the nature of sexuality, gender etc

Values exploration

Making individual spirituality/philosophy more explicit

Exploring individual meanings in relation to loss, death, transition etc




12-Step work

Compassion-Focused Therapy

Exploring voluntary work, giving to community

Exploring Literature, History, Art

A detailed list like this has implications for Training & Development in Integrative CBT, which obviously requires a wide range of abilities. Many therapists are very skilled in some of the 5 levels, and not in others. Some may have skills at all 5 levels, but don’t conceptualise their work overall in a Cognitive way. Others have a set of CBT skills, but little training in relational therapy skills or longer-term developmental work. Many have some training and experience in pretty much everything else but good, evidence-based, Level 3 CBT. Only a very few have a well-thought-out view on human nature, based on wide-ranging study and reflection on lived experience. Training is something which I will come back to in a later blog.

For now, goodbye from Manchester...

Tuesday 13 July 2010

Judith Beck on CBT Myths

Go to:

A few days ago, Judith Beck, president of the Beck Institute for Cognitive Therapy and Research and daughter of Aaron T. Beck, posted this blog on the Huffington Post, which I thought was worth re-posting here.

Thursday 8 July 2010

Case example 1, Part 2

My work with Richard continued on various fronts for about 12 weekly sessions, after which he came less regularly to monitor progress. The areas of principal focus were always agreed collaboratively and explicitly, although I provided strong guidance and direction, based on my experience of the kind of issues he was struggling with.

Level 3:
We initially focused primarily on trying to weaken some of the maintaining cycles of Richard’s social anxiety problem, in order to give him some relief, hope and energy. He borrowed a copy of “Overcoming Social Anxiety: A Self-help Guide using Cognitive-Behavioural Techniques”, and found this useful in educating himself about the problem and the ways in which it can be addressed.

The classic Social Anxiety pattern, as described a couple of weeks ago, consists of tendencies
• To worry and mentally rehearse before social events
• To practice a range of “Safety Behaviours” in social settings
• To carry out a self-critical “post mortem” after social events.

Richard did not do a lot of the pre-event rehearsal and anticipation, because of his huge avoidance of (and avoidance in) social settings, but he was quite capable of self-punishing post-mortems, “chewing over” almost any interpersonal encounter in a negative way. We worked together to try and get a sense of what was going through his mind when he was feeling anxious during and after social situations, and discovered that the following Negative Automatic Thoughts were common for him:

“I’m different”
“They don’t like me”
“They’re only being nice”
“I look/sound stupid”
“I made a mess of that”

He could also identify typical cognitive distortions such as All or Nothing Thinking, Discounting Positive Feedback, Mind-reading, Emotional Reasoning, and Catastrophising.

We agreed that, in order to reality-test some of these in an experiential way, he must, at some point, begin to drop some of his safety behaviours, and see what happens. Some of his main safety behaviours were:
• Avoiding eye-contact and conversation – he would spend minimal time in the staff room, preferring to stay busy, volunteering for every possible activity with pupils
• Sticking to task-oriented, work-related conversation
• Avoiding social outings (pubs, parties etc).

Fortunately he had never developed the habit of using alcohol to cope with social situations or with his loneliness, so this was not an issue.

Level 1:
Lots of support was needed, as Richard was very fearful of even thinking about changing any of these patterns. The therapeutic relationship was very important in this regard, as well as in the use of Immediacy, by providing positive feedback as to how Richard was coming across in the therapy relationship.

Level 2:
This opened up the possibility of rehearsal and practice. Richard feared that his social skills were poor, but in fact they were mostly fine, apart from the lack of practice that comes from too little time spent with people and too much time spent with a computer.
Reality-testing his fears took a lot of courage, so we also did some motivational work on risk assessment and cost/benefit analysis.

Level 3:
Fortunately, when Richard took the risk to make a little more eye contact, and to ask colleagues about their holidays etc, he was amazed at how much less awful it was than he had feared it would be. Of course, this result was in large part due to appropriate cognitive preparation and therapeutic support.

Level 4:
Richard made so much progress that he began to be puzzled as to how his problems could have been so deeply ingrained, so we talked again about the maintaining cycles and blocks to experiential learning. We also spent some time again talking about the early maladaptive schemas that were probably part of the roots of his difficulties. His father had had very rigid rules for the family, and no friends were allowed to visit the home. This had always embarrassed Richard greatly, and his sense of shame and his withdrawal had gradually reinforced each other to the extent that even when he left home to go to college, he still felt very different from everyone else. This in turn left him still very dependent on his parents for his age, and one of the Level 2 skills we needed to work on was Assertiveness.

Level 5:
We also discussed the fact that people vary in their sociability, both in amount and in style, and that it was important that he develop his own way, rather than try to be too much of what he thought he “ought” to be. I also reassured him that relationships could be difficult for everyone at times, and that now that he was getting more confident and considering the possibility of dating, the fun was only starting!