Wednesday 29 September 2010

Reality-Testing the Beliefs we Live by: Using Behavioural Experiments

Behavioural Experiments are crucial to working at Level 3 of the Integrative CBT model, and build on Socratic questioning in an ongoing process of guided discovery. Guided discovery (which can also be called collaborative empiricism, trial & review, corrective experience, etc) is the heart of the cognitive-behavioural process of experiential relearning.

Here is one description of the concept of behavioural experiments:

“Behavioural experiments are planned experiential activities, based on experimentation or observation ... Their design is derived directly from a cognitive formulation of the problem, and their primary purpose is to obtain new information which may help to test the validity of ... existing beliefs about themselves, others, and the world...” (Bennett-Levy, J. et al, eds, 2004, Oxford Guide to Behavioural Experiments in Cognitive Therapy. Oxford: OUP – p.8).

Behavioural Experimentation is therefore crucially different from the Behavioural Intervention/Change process which is central to Level 2. Behavioural intervention/change work always focuses 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, meditating, eating more healthily, cutting down on drinking, treating oneself well, etc).

Behavioural experimentation on the other hand might equally focus on “bad” behaviours (e.g. leaving a task unfinished, staying up all night, not being “nice” to everyone, etc), since just as much (or more) can be learned experimentally/experientially from the results of such experiments.

An important related point is that behavioural intervention/change work always focuses directly on central areas in the client’s life that need improvement (e.g. socialising, travelling etc), because the main goal is positive change in the client’s daily behaviour and environment. Behavioural experimentation, on the other hand, often works better if it focuses on areas of the client's life which are less central, but where fruitful experiential relearning is more likely to occur. This is because the stakes are less high in these situations, and new learning is less blocked by negative cognitions and high negative emotions. A behavioural experiment sometimes focuses on something quite small, and it may therefore seem trivial to a client, but it needs to be explained that the main goal is some bit of adaptive change in the client’s cognitions.

Some common examples of behavioural experiments are:

• Asking a depressed client to try drinking a cup of tea more slowly than usual, and with a little more mindfulness. As with all behavioural experiments, it is vital that they first of all make a relevant prediction about this. Here the prediction would be a rating between 1 and 10 as to how much they think they will enjoy drinking the tea. Because of the nature of depressive cognitions, they will nearly always underestimate this, and be pleasantly surprised as a result. This serves both to briefly increase their sense of the potential “rewarding-ness” of their environment, but more crucially it also slightly loosens the grip of their depressive beliefs.

• Suggesting to a socially anxious client that they deliberately make themselves blush (perhaps by agreeing to meet and chat with a colleague of yours for a few minutes). Some socially anxious clients have a range of beliefs about blushing, e.g. “I go as red as a fire engine”, “Everybody notices”, “They think I’m pathetic”. Because they believe these things are true, the last thing they want to do is actually face them and check them out, but this is exactly what is needed. The “fire-engine-red” theory can nowadays easily be tested (and falsified) by the use of video recording and replay.

• Suggesting to a client who suffers from panic attacks, and who believes that they are going to have a heart attack when they experience the tightness in the chest which anxiety brings, that they run up and down the stairs rather than sit down and try to calm themselves. This tests the prediction that they would have had a heart attack if they hadn’t minded themselves carefully, and kept their arousal level low, by deliberately increasing their level of physiological arousal (it is generally advised that they have had a check-up from their GP first, just to rule out genuine heart problems – some dangers are real, occasionally!)

All of this is designed to break down self-perpetuating emotional-cognitive-behavioural Vicious Cycles, which can block out experiential relearning for a lifetime if they are not properly addressed. Behavioural experiments are one great way of doing this, and they can be wonderfully immediate, vibrant and exciting (not to mention scary) for both client and therapist.

More on vicious cycles in next week’s blog...

Wednesday 22 September 2010

Don't Believe Everything You Think: The Power of Socratic Questioning

Integrative CBT case formulation and intervention, while obviously making room for all five levels, are primarily based on the Beck/Ellis theoretical perspective of Level 3, namely that mental health problems are mainly cognitive in their nature and their roots, and are most effectively helped by achieving relevant cognitive change.

This means that we need to help the client get to the cognitive heart of the matter, which is often not all that obvious. In many anxiety problems, for instance, the client is not actually clear what it is precisely that they find threatening. A common example is fear of flying. To be afraid of flying can mean different things: fear of crashing, fear of dying, fear of not being in control (this is one reason why many who fear flying are not nearly so afraid of crashing in their car, even though the latter is much more likely), fear of panicking, of feeling enclosed (so in fact a form of claustrophobia), fear of leaving their children without a parent (this is why many people are more afraid, rather than less afraid, when they are flying in the company of their spouse).

The primary CBT process which is used in this regard is called Socratic Questioning or Socratic Dialogue. This is a cognitive/empathic process which tries to tease out what the client has learnt from their experiences, in other words to help them become clearer about some of their crucial beliefs, which are based on relevant experiential learning. This leads on to a 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. So Socratic Questioning starts out as an exploratory process, and gradually becomes a more challenging, change-oriented process, fostering more functional, adaptive ways of interpreting the important aspects of our lives.

Therapeutic change may take place not just in the content of beliefs, but also in the way they are held, i.e. they may be held more provisionally, more flexibly. In this sense, Socratic Questioning is a philosophical method, an educational method, a part of critical thinking. Its function is to probe & test assumptions, viewpoints, ways of seeing things. It is not just a therapeutic tool; the following list, for instance, has been adapted from Paul, Richard - "Critical Thinking: How to Prepare Students for a Rapidly Changing World" (1993), and yet is very relevant to the therapeutic setting.

• Let me see if I understand you; do you mean _____ or _____?
• Could you give me an example?
• Could you explain that further?
• Do I understand you correctly? You seem to be assuming ____.
• What could we assume instead?
• Why would someone make this assumption?
• Is it always the case?
• Why do you think that is true?
• Do you have any evidence for that?
• What would change your mind?
• What would you say to someone who said ____?
• How could we find out whether that is true?
• Where did you learn this?
• Have you always felt this way?
• When you say ____, are you implying ____?
• Would that necessarily happen or only probably happen?
• You seem to be approaching this issue from ____ perspective.
• What might someone who believed ____ think?
• What would someone who disagrees say?
• What is an alternative way of seeing this?

In the therapeutic setting, this method can lead on to other forms of Guided Discovery, especially Behavioural Experiments (which will be explored in next week’s blog).

The Socratic Method goes back, as the name suggests, to the Ancient Greek philosopher Socrates (who was executed for his persistent questioning of widely-held beliefs), but does not necessarily fully reflect the style and philosophy of the original Socratic dialogues of Plato, which personally I never much took to. But I’ve always been fascinated by the nature of beliefs, where we get them from, why we keep them, why we change them. I love critical thinking, and the process of examining views from every possible angle; and a bit like Socrates, what I’ve discovered personally is that once you start doing this in a committed way, it may lead anywhere...

Wednesday 15 September 2010

Sexual Addiction: Integrative CBT Case Formulation, Example 2

This second example applies the Integrative CBT Case Formulation model to a case example where the main issue is sexual addiction.

Once again, the relevant questions, which follow the 5 Levels of Integrative CBT, are:

How do I best connect with this particular person, and form a therapeutic relationship with them?

What are the immediate problems that need action?

What is the individual psychology/psychopathology of this person? What are their typical cognitive distortions, automatic thoughts, compensatory behaviours, maintaining cycles?

What are the developmental sources of the above difficulties? How does this client see the world, what are their Core Beliefs?

What core human issues are they struggling with?

"Larry" (age 53) came for therapy because his wife had given him an ultimatum. She had found him using Internet pornography yet again, after he had repeatedly promised not to. He was also increasingly neglecting his work as a self-employed architect (there had been less work recently, anyway, so this was also getting him down).


Having been “sent” for therapy because of his “misbehaviour”, Larry was initially mistrustful of therapy and of my role. He was also very ashamed and uncomfortable when it came to talking about the subject of his sexual behaviour. Therefore, the initial therapeutic tasks were to engage with him and form a working alliance, and to project a non-judgmental concern about his situation, normalising it by emphasising its familiarity, while not minimising or justifying. A currently active addiction problem like this may also require a relatively firm and direct stance; the reality of the addictive behaviour and its consequences do need to be discussed openly early on in therapy, as time and options may be running out. For instance, Larry talked about there being other problems in his marriage apart from his pornography use, but we needed to agree to come back to those later.


If negative consequences were reason enough to stop, addiction would not be the problem it is. Ambivalent motivation is central to all addictions (“I wish I wanted to stop, but I actually want to continue to look at porn”), so this would need to be explored with Larry, and some cognizance taken of his current stage on the Wheel of Change (probably somewhere between Pre-contemplation, Contemplation, and Preparation/Determination; see Miller & Rollnick, 2002). The natural negative consequences of continuing the addictive behaviour may need to be revisited here, perhaps in the context of a Cost/Benefit Analysis. With Larry, I would be looking at the threatened loss of his marriage, but also the pain caused to someone he loved, his loss of self-respect, his neglect of his work and other important areas of his life, etc.


As with other disorders, a central reason for the continuation of an addiction, despite the damage it causes, is its Vicious Cycle nature (vicious cycles are central to the Cognitive theory of how psychological disorders are maintained, and will be explored in more detail in a later blog). This insight is at the heart of my own definition of addiction:

A progressively tolerated & progressively damaging

biopsychosocial adaptation to/dependency on

(and therefore preoccupation/obsession with)

the initially intensely mood-altering,

but ultimately only superficially satisfying,

emotional rewards (pleasure and/or pain-relief)

provided by certain artificially-enhanced activities (and their associated rituals),

which require minimal personal investment

(e.g. heroin use, gambling, pornography use, etc)

leading to a self-perpetuating cycle of compulsive behaviours in some of the above areas,

which the addicted person sometimes tries to control, with limited success,

when crisis points are reached

(including the crisis of withdrawal,

but also in response to serious negative consequences

in such areas as health, relationships, finances, employment, legal problems etc),

but which they otherwise resist acknowledging by using

various cognitive-emotional avoidance strategies (distortions/defenses).

A discussion of what it means to be addicted is often essential in this kind of work, and runs through all five levels of Integrative CBT (initial naming of issues, realistic action-planning, cognitive-emotional restructuring, facing underlying issues, understanding addictive human nature). If the addicted client is to make any real progress, their individual rituals, distortions, preoccupations, settings, triggers etc, need to be explored and owned in scrupulous detail. For Larry, some of these would be: being on his own in the house, being stressed and irritable, having the laptop already switched on for other purposes, looking forward to using porn all day, telling himself he deserves it, etc. All of these factors will need to be explored, challenged and changed to some degree in order for Larry to gain freedom from his compulsive behaviour.


It is not always the case that there are underlying dysfunctional core beliefs in cases of sex addiction, but it is certainly common (see Carnes 2001, and my Masters thesis at this link). Typically, we might expect maladaptive schemas in areas such as Abandonment, Shame/Self-hate, Entitlement, Mistrust etc. These are likely to have their roots in such early experiences as family alcoholism, violence or abuse, neglect or bullying. Larry’s story was one of alcoholism in both parents, along with depression in his mother, and bullying from elder siblings. His core beliefs certainly made sense in the light of his early learning experiences.

These areas need to be explored, but may be too delicate to work on until there is some stability in recovery.


Of all the issues that I have worked with, one of the most shameful for many people is Sexual Addiction. This is partly due to its associations with perversion and sexual offending, but also arises from beliefs about the “dirtiness” of sexuality itself (a legacy of many Irish Catholic childhoods).

Understanding and humanising the behaviours, thoughts and feelings involved in sexual addiction is not the same as giving permission for the damaging behaviours. But, unless Larry is helped to understand how his addiction has its roots in the nature of human (male) sexuality, his recovery may remain lacking in self-acceptance and humanity.


Carnes, P. J. (2001) Facing the Shadow: Starting Sexual & Relationship Recovery. Wickenburg, AZ: Gentle Path Press

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

Wednesday 8 September 2010

Depression: Integrative CBT Case Formulation, Example 1

In this week’s blog, I’m applying the questions outlined in last week’s blog to a case example involving depression. These questions, which follow the 5 Levels of Integrative CBT, are:

1. How do I best connect with this particular person, and form a therapeutic relationship with them?

2. What are the immediate problems that need action?

3. What is the individual psychology/psychopathology of this person?
What are their typical cognitive distortions, automatic thoughts, compensatory behaviours?
What is the inner logic of their irrational problems?
What are the relevant emotional and physiological factors, and maintaining cycles?

4. What are the developmental sources of the above difficulties?
How does this client see the world, what are their Core Beliefs?
What has been their relevant experiential learning?

5. What core human issues are they struggling with?

"Jane", aged 37, has been struggling to cope ever since she was promoted to a higher level of responsibility in her job a year ago. She has had growing difficulty getting up in the morning, her appetite and sleep are poor, and she is increasingly neglecting both work tasks and leisure activities.

Jane comes across as emotionally flat, makes little eye contact, and says she has little hope that therapy will help her, therefore extra effort in terms of warmth and positivity is needed by the therapist to connect and to encourage. The therapist may also need to take care not to become overly influenced by Jane’s negative outlook, so that they can retain a hopeful outlook themselves in relation to the therapy.
Her global hopeless thinking may also require a gentle exploration in relation to possible suicidality.

Jane has been referred by her GP, who has also suggested that she try anti-depressants. Jane is unsure how she feels about this, or how to come to a decision, so this needs some discussion in terms of accurate information, pros and cons, how we might monitor and review either decision, etc. Other immediate issues, such as who she might tell about her situation, also need to be looked at.

The pattern of Jane’s depression will of course be both classic and individual. We expect Negative Automatic Thoughts about herself, her world and her future, and we need to find out what her own specific ruminations and self-talk in these areas are. We would expect themes such as: “I can’t cope with this”, “There’s no point in my trying”, I’m useless”, etc.
She also clearly has avoidance behaviours, which makes sense from her point of view, since her life is likely to seem both unrewarding and anxiety-provoking. Again these need to be teased out on an individual level, and the vicious cycles between her thoughts, behaviours and emotions made clearer and more visible.
This part of the case formulation will suggest where some of the most immediate interventions need to take place, in order to increase the client’s level of functioning, and to provide them with the skills to do this for themselves in the future. In Jane’s case, some of the classic CBT techniques would probably be helpful, e.g.: gradual increase in non-threatening, mildly rewarding behaviours such as going for a walk; monitoring of negative ruminations, so as to at least gain some distance from them, and possibly even test them for validity (more recent techniques such as Mindfulness practice could also be a useful addition here).

Beck’ theory of depression contends that amongst the sources of an individual’s vulnerability to depression we will find Cognitive Vulnerability. A detailed exploration of this aspect of Jane’s formulation may need to wait until later in therapy, when she is more able for it (and when relapse prevention is becoming the main focus), but an initial history-taking may well suggest some relevant early experiences and subsequent belief-formation, such as a belief in her own fundamental incompetence. As it happens, she describes a mother who both was and is highly critical, especially of Jane as the eldest in the family. Feeling that she wasn’t good enough, and couldn’t get anything right, has been a familiar experience for Jane throughout her life.

Given that Jane is highly critical of herself, she is likely to be highly critical of the fact that she is suffering from depression, and this turns out to indeed be the case. She sees being depressed as “weak” and “pathetic”. This is an attitude which needs to be taken into account by the therapist at all the other levels of work. It will influence the therapist’s efforts
- to form a functioning therapeutic relationship
- to facilitate the making of important practical decisions in areas such as seeking support
- to tease out with the client their individual vicious cycles and underlying belief structures.
This is why it may be important to explicitly discuss this issue at this fundamental level, in an effort to set depression in a more acceptable, human context. I would tend to do this at quite an early stage of therapy, if it seems necessary, by discussing the nature of depression with the client, including its prevalence as a response to ongoing stress and challenge, and its possible evolved function as a form of psychological “retreat”.
The Integrative CBT case formulation can also hold open the possibility of returning to these issues later, if the client wants to try to put a larger spiritual/philosophical perspective on their depression and recovery. Jane, as it happens, is quite a spiritually-oriented person, and may well want to put some meaning on her painful and disruptive experiences in retrospect.

Next week’s blog will look at another case formulation example, with a sexually-addicted male client.

Wednesday 1 September 2010

I Love it when a Plan Comes Together: Case Formulation in Integrative CBT

Case Formulation in Counselling/Psychotherapy can be seen as consisting of

(a) a hypothesis, or set of hypotheses, concerning the sources and maintaining factors of the client’s presenting psychological problem(s)
(b) a plan, based on the above hypotheses, as to when, where and how to intervene, with a view to bringing about some reduction in the client’s problems.

The Case Formulation process therefore guides and structures the course of treatment by unifying and prioritising symptoms, influencing the choice and timing of interventions, and predicting possible difficulties. It should be an ongoing process, open to modification at any stage.

This process is not carried out explicitly in all forms of counselling/therapy, though presumably all therapeutic intervention must be based on some such hypothesising and planning, even if it remains largely implicit. Carl Rogers considered that “a diagnosis of the psychological dynamics is not only unnecessary but in some ways is detrimental or unwise” (1951, p. 223). He was concerned that the process of making a diagnosis leads to an inequality in the power dynamic between counsellor and client. Similar concerns are part of Integrative CBT (at Level 1), but I believe that a collaborative approach to arriving at a formulation should resolve this difficulty. In practice, this means that the therapist presents his own formulations to the client as hypotheses for discussion, and also helps the client to formulate his own hypotheses through guided discovery (J. Beck, 1995). The client should have as full as possible an understanding of what is happening in their own treatment. As Persons remarks (1989, p. 48), ‘If the formulation is so helpful to the therapist, we might also expect it to be helpful to the patient in understanding and managing his behaviour.’

In Integrative CBT, developing the hypothesis is an explicit process, and is part of the work that we do at Levels 3 and 4. Because this is “Integrative Cognitive Behavioural Therapy”, and not just Integrative Psychotherapy in general, the formulation is based on the Cognitive Model of emotional disorders, which “proposes that distorted or dysfunctional thinking (which influences the client’s mood and behaviour) is common to all psychological disturbances” (Judith Beck, 1995, p. 1). As we have seen in earlier blogs, at its simplest level it focuses on Negative Automatic Thoughts which are locked into vicious cycles with dysfunctional emotions, behaviours and physiology. It can also be expanded to include more ongoing dysfunctional underlying cognitions in the form of Assumptions and Core Beliefs.

So the questions an Integrative CBT therapist would be asking themselves about any client would be:

1. How do I best connect with this particular person, and form a therapeutic relationship with them?

There are some general principles here, of course, but also individual differences in how we need to adjust to different clients. Our initial therapeutic engagement will be based on initial impressions, but this can be adjusted in line with whatever emerges at the next levels of exploration. For example, a currently active addiction problem may require a firmer and more directive stance; hopeless thinking may require a gentle exploration of possible suicidality; mistrust and abandonment schemas may require reassurance and clearer discussion of contractual boundaries.

2. What are the immediate problems that need action?

Often the client and therapist agree to work on the most urgent problems, i.e. the most damaging ones, first. But there are also other possible criteria for prioritising problems, such as the likelihood of achieving reasonably quick progress (thereby raising hope and increasing motivation). And new priority issues may emerge as therapeutic exploration continues, especially at Levels 3 and 4.

3. What is the individual psychology/psychopathology of this person?
What are their typical cognitive distortions, automatic thoughts, compensatory behaviours?
What is the inner logic of their irrational problems?
What are the relevant emotional and physiological factors, and maintaining cycles?

Sometimes the pattern which emerges fits well into an existing diagnostic category such as Social Anxiety (see e.g. the Case Example blog from 30 June); in other cases it is a more idiosyncratic mix. But this distinction is a continuum, not a dichotomy – there is always an individual aspect to the most textbook diagnosis, and familiar patterns in the most idiosyncratic psychopathology.

4. What are the developmental sources of the above difficulties?
How does this client see the world, what are their Core Beliefs?
What has been their relevant experiential learning?

This is a crucial piece – it can help clients enormously to see that their problems, and dysfunctional strategies, can actually make sense in the light of their underlying beliefs, and that these beliefs in turn can make sense in the light of their core learning experiences.

5. What core human issues are they struggling with?

It can also be helpful for both client and therapist if problems are seen in their larger human context. Social Anxiety problems, for instance, can be seen as understandably arising in relation to such central human concerns as Status, Belonging, Community, Reputation etc.

As mentioned above, the formulation which emerges at these later levels may in turn influence the style and focus of our work at Levels 1 and 2.

What I have described at levels 2, 3 and 4 are classic Cognitive Case Formulation; 1 and 5 are essential to any good therapy work, whether Cognitive-Behavioural, Humanistic or Psychodynamic. I believe that only Integrative CBT Case Formulation clearly combines them all.

Next week, some I plan to discuss some case examples from an Integrative CBT Case Formulation viewpoint, which hopefully will make everything clear...!


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

Persons, J.B. (1989) Cognitive Therapy in Practice: A Case Formulation Approach. New York: W.W. Norton.

Rogers, C.R. (1951) Client-centered Therapy. Boston