Wednesday 27 October 2010

Continuity and Collaboration: the role of "reviewing", "feedback" and "homework".

Cognitive Therapy (and other CBT approaches) are well-known for their focus on structure, goal-setting, agenda-setting, homework, practice, reviewing, etc. Indeed, Judith Beck, whose blog I have featured here a couple of times, outlines ten Principles of Cognitive Therapy, at least five of which (3, 4, 6, 7, 8) refer to these areas:

1. Cognitive therapy is based on an ever-evolving formulation of the client and their problems in cognitive terms.

2. Cognitive therapy requires a sound therapeutic alliance.

3. Cognitive therapy emphasises collaboration and active participation.

4. Cognitive therapy is goal oriented and problem focused.

5. Cognitive therapy initially emphasises the present.

6. Cognitive therapy is educative, aims to teach the client to be his or her own therapist, and emphasises relapse prevention.

7. Cognitive therapy aims to be time limited.

8. Cognitive therapy sessions are structured.

9. Cognitive therapy teaches clients to identify, evaluate and respond to their dysfunctional thoughts and beliefs.

10. Cognitive therapy uses a variety of techniques to change thinking, mood and behaviour.

She also provides a recommended structure for the initial session (post-assessment):

Setting agenda

Checking mood

Update on presenting problem

Identifying immediate issues to work on, and setting goals

Educating client about the cognitive model

Eliciting expectations for therapy

Educating client re specific diagnosis

Setting homework

Providing a summary

Inviting feedback

(J. Beck, 1995)

Integrative CBT does believe in the importance of structure, and of processes like homework and feedback which help to provide some structure, but it is not necessary to be as organised as Judith Beck. It can be helpful in some cases to work at the highly-structured end of the continuum (e.g. with very chaotic clients, with children or adolescents, with groups in institutional settings, etc), but Integrative CBT also allows for a more non-directional approach, especially at Levels 1 and 5.

The key issue is continuity, building on gains made, internalising learning. We all know the situation where we have had a really good session with a client one week (lots of insights, changes, hope, etc) only to find that it has completely disappeared the following week, as if the previous session never happened (in fact, sometimes the client seems to have literally forgotten the previous session, even after promptings from the therapist). The idea of therapeutic structure, as I understand it, is to increase the chance of sustaining and building on therapeutic change and learning. Only to increase the chance, I’m afraid - there is no guaranteed way yet (I’m working on it…)

Reviewing progress, getting feedback from the client, revisiting and revising goals – all of these processes should be built into therapy in an ongoing way, not just done occasionally. Most important of all is the concept of “homework” (a word, incidentally, which I try to avoid using with clients, because of the negative, disempowering connotations it has for many people). If clients are to ultimately learn to be their own therapists (see point 6 above), they need to do most of their discovery, practice and experiential relearning out in the world outside the therapy room and in the time outside the therapy hour. In other words, the best collaboration is one where the client does most of the work.

Which brings us to another question: Does the therapy session need to last one hour (or the “50-minute hour”)? Integrative CBT is a pragmatic approach. Its aim is to give the professional help that the client actually needs, where possible - to be, as they say, “fit for purpose”. If a client reaches the stage where they will benefit more from attending for half an hour, in order to update, review and plan, then ideally the therapist should contract for half-hour sessions. Of course, this may not suit the therapist for practical reasons (e.g. scheduling, or the fact that the client is paying less), but that’s another issue. Similarly, there is no therapeutic need for every client to come every week – the crucial test, again, is whether continuity of progress is being achieved. If most of this progress is being achieved outside of therapy, all the better – this is, after all, the goal of therapy.


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

Thursday 21 October 2010

The Worse it Gets, The Worse it Gets: The Viciousness of Vicious Cycles

CBT is sometimes thought of as being “just common sense”. While common sense is of course essential in the practice of any form of professional helping, it should be clear from some of the previous blogs that there is much more to CBT than this. Socratic Questioning and Behavioural Experimentation, for instance, are often quite counter-intuitive and are not part of the way we ordinarily think; the same applies to the important idea of Vicious Circle Causality.

The human mind generally tends to think of causality in a linear way, where “one thing leads to another”, and of course this the way things happen a lot of the time. But causal processes can also loop back on themselves, leading to cyclical processes which can become stable and self-sustaining, and may even spiral out of control. We are aware of this, of course, in relation to examples such as “The Snowball Effect” (the bigger the rolling snowball gets the bigger it gets) and “Arms Races” (the more weapons they have, the more we have to have; the more we have, the more they have to have). However, we don’t habitually think of our own mental and behavioural processes in this way (therapists, of course, often use exactly the kind of examples I have just given as metaphors in helping clients to understand some of what is happening in their lives).

This is one of the ideas in CBT which first engaged my interest, and I’ve found it to be a very powerful concept in helping to understand and work with many mental health problems. The idea is not, of course, unique to CBT, but CBT as an approach does put a stronger emphasis than some other approaches on the perpetuating, maintaining factors contributing to a mental health problem along with the predisposing and precipitating factors.

This emphasis is valuable in three main ways:

As a description: Finding the relevant vicious cycles can make sense of the stuckness that a client experiences in relation to their depression, anxiety, anger etc. As I have emphasised previously, the presence of vicious cycles tends to block the experiential re-learning necessary for recovery and growth. Such cycles tend to take on a dynamic of their own, relatively unaffected by other influences such as the environment.

As an explanation: The progressive nature of vicious circular processes can help make sense of how the client developed such a serious problem, especially if there is no obvious major cause in their developmental history. The fact that a major problem does not have to have a major cause is one of the ideas presented here which go against “common sense”.

As a generator of hope: If we understand some of how the problem is being maintained in a circular way, then this may help makes sense of possible ways out; the good news is that positive changes in thinking, behaviour, mood etc are also processed through the cycle, reversing the downward progression and making the cycle no longer vicious (a “virtuous circle”?).

As I described in an earlier blog (25 May), a basic Case Formulation can be put together with a client by identifying vicious cycles of thoughts/feelings/behaviours/physiology that are keeping a problem going.

For instance, in a depressed client, their negative thoughts feed their depressed feelings, lack of activity, and exhaustion, and are in turn reinforced by each of these symptoms (lack of productive activity reinforces a negative self-view, lack of rewarding activity reinforces low mood, etc).

In recent years, a number of clinicians and researchers have developed models of the typical vicious cycles found in mental health problems such as Depression, Social Anxiety, Panic, OCD, Substance Addiction, etc.

Here are a couple of examples which I have found to be indispensable:

Panic (Clark, 1986):

The catastrophising misinterpretation (“I’m having a heart attack”) of anxiety symptoms, such as tightness in the chest and heart palpitations, are the crucial element which closes the cycle, leading to further and further increases in anxiety. Reduction in the strength and plausibility of these cognitions (through Psychoeducation, Socratic Questioning, Behavioural Experimentation etc), can completely dissolve the cycle in many cases.

Sexual Addiction (Carnes, 1983):

According to Carnes,

“For sexual addicts an addictive experience progresses through a four-step cycle, which intensifies with each repetition:

1. Preoccupation: The trance or mood wherein the addict’s mind is completely engrossed with thoughts of sex. The mental state creates an obsessive search for sexual stimulation.

2. Ritualization: The addict’s own special routines, which lead up to sexual behaviour. The ritual intensifies the preoccupation, adding arousal and excitement.

3. Compulsive sexual behavior: The actual sexual act, which is the end goal of the preoccupation and ritualization. Sexual addicts are unable to control or stop this behaviour.

4. Despair: The feeling of utter hopelessness addicts have about their behaviour and powerlessness.

The pain the addict feels at the end of the cycle can be numbed or obscured by sexual preoccupation, which re-engages the addiction cycle.”


Carnes, P. J. (1983) Out of the Shadows: Understanding Sexual Addiction. Minneapolis: CompCare.

Clark, D. M. (1986). A Cognitive Approach to Panic Disorder. Behaviour Research and Therapy, 24, 461–70

Wednesday 13 October 2010

Social Anxiety: November Conference, and a Blog from Judith Beck.

I’m putting off the discussion of Vicious Cycles for another week (just building the suspense…).

Instead I’m going to once again feature Judith Beck’s Cognitive Therapy blog from the Huffington Post, this time because it’s on the topic of Social Anxiety. As readers of this blog will know, Social Anxiety is one of my main areas of interest, and I will be involved in a one-day conference on the topic in Dublin on November 28th.

For more information on the conference see this link.

Conference topics will include The Neurobiology of Social Anxiety, CBT for Social Anxiety, Social Anxiety and Alcohol Problems, Groupwork with Social Anxiety, Social Anxiety and Sexual Addictions.

In the meantime, enjoy Judith Beck’s account of her work with a socially anxious client, “Using Socratic Questioning to Help Social Anxiety”, by going to this link.

Wednesday 6 October 2010

Being a Worrier: Generalised Anxiety Disorder

“I am an old man and have known many troubles, but most of them never happened”
- Mark Twain

I’m postponing the blog on Vicious Cycles for another week, because I’ve had the topic of Worry on my mind (because it’s World Mental Health Awareness Week, and anyway there’s no shortage of worry around these days…)

Worry is common and normal - we all worry sometimes. In other words, we anticipate what could go wrong, we imagine a range of possible negative scenarios, we speculate “What if...” in every possible variety. But usually we snap out of it (at least until the next time...)

This is not pleasant, and most of us could probably benefit from doing less of it, but it doesn’t destroy our lives. Some people, however, develop a major worry problem – they become worriers. When does worry become a serious problem?

When worry is compulsive, hard to control, excessive, inappropriate (i.e. usually about minor things), circling around the same anxious predictions again and again, then we have a real mental health issue. This type of compulsive worry is called Generalized Anxiety Disorder (GAD). People with this problem worry excessively about a variety of things (e.g., job, money, family, health), and as the problem develops, more and more of the worry is about hypothetical scenarios, rather than about real challenges. Along with persistent feelings of anxiety, physical symptoms also tend to develop, such as muscle tension, headaches, and difficulty sleeping

4-7% of the population will develop GAD at some point in their lives, women slightly more than men. In terms of remission, GAD symptoms rarely abate naturally over time.

From a Cognitive-Behavioural perspective, GAD has four main features:

1. Intolerance of uncertainty
2. Positive beliefs about worry
3. Negative problem orientation
4. Cognitive avoidance.

1. Intolerance of uncertainty:

Understandably, we mostly worry about things where the outcome is uncertain. Worry is a natural reaction to uncertainty and it can be seen as a way of trying to predict the future and manage the experience of uncertainty. People with a worry problem tend to be especially uncomfortable with uncertainty. Some would even prefer bad things to happen rather than live with the sense of not knowing what will happen next.

However, worrying generates more uncertainty, which in turn fuels more worry.

Behavioural experiments (see last week’s blog) are one Cognitive-Behavioural technique for working to increase tolerance of uncertainty; here the client deliberately does something more uncertain than usual, to test if it is actually as intolerable as they fear, for example:

• Going to see a film they know nothing about
• Going to a different shop for their groceries
• Ordering something they have never had before in a restaurant
• Making opportunities to meet new people
• Breaking routines

2. Positive beliefs about worry:

Compulsive worriers tend to believe that worry helps in some way, though they may not be fully conscious of this. Some common beliefs they may have are:

• Worry finds solutions to problems
• Worry motivates me to do things
• Worry protects me from possible dangers
• Worry prevents possible dangers from happening
• Worry shows I care

Once people become fully aware of these beliefs, they usually begin to see that there is little evidence to support them.

3. Negative problem orientation:

Worriers tend to use unhelpful strategies to try to solve problems, for example:

• Seeking reassurance for decisions (which keeps worry going, as the worrier never learns to trust their own judgement)
• Seeking out excessive information before making a decision
• Making lists as a substitute for actions
• Being overly busy, throwing oneself into activity rather than solving problems (e.g. cleaning)
• Procrastination
• Post-mortem worry: “What if I have made the wrong decision?”

GAD sufferers need to be taught more helpful strategies of problem-solving and decision-making, such as realistic risk-assessment, cost-benefit analysis, trial-and-review, etc.

4. Cognitive avoidance:

Because excessive worry is distressing, many GAD sufferers become worried about their worrying, so they try to go to the other extreme, and push all upsetting ideas out of their mind. This is not a helpful strategy either, as real concerns and issues do need to be faced, and “fearing fear itself” does not improve the situation.

Sufferers are often invited to write down their worries so that they can be faced squarely, and even to set aside a specific “Worry Time” every day, for which they save all their worries. During the specified Worry Time, they are encouraged to worry as hard as they possibly can – this tends to change their relationship with worry as a habit, and can sometimes even be an amusing experience!