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...

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