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
Contracting
Pacing
Attending
Active Listening, including non-verbal
Reflecting
Paraphrasing, summarising
Prompting, evoking
Empathising
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
Problem-clarification
Psychoeducation
Goal-setting
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
Self-monitoring
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
Immediacy
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
Catharsis
Individualised, longitudinal, developmental Case Formulation
Imagery, visualisation
Rescripting
Metaphor
Writing
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
Self-disclosure
Immediacy
Meditation
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...
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