Tuesday 3 May 2011

Where Are We Now? – Reviewing Therapeutic Progress Using the 5 iCBT Levels

The 5 Levels of Integrative CBT outlined in these blogs can be a useful tool for reviewing where therapy is going, especially if it is stuck. This is something a therapist can carry out in their own mind as they reflect before and after sessions; it can also take place as an explicit discussion between therapist and client; or it can happen, of course, in supervision, which can make Integrative CBT another useful model for supervisors.

Level 1:

This is the primarily Relational level, where the focus is on immediacy of contact and connection with self, therapist, and others.

Useful review questions on this level are:

How solid is the therapist-client contact? Has it been well-established to start with? Does it need to be revisited/re-established?

How solid is the client’s contact with themselves? Can they access relevant feelings?

While Integrative CBT practitioners don’t believe it is sufficient in most cases for the therapeutic focus to stay solely on the relational level, we do run the risk of losing sight of this level as we get engrossed in problem-solving, cognitive restructuring etc (see 12th May 2010 blog: http://integrativecbt.blogspot.com/2010/05/exploring-level-1-therapeutic.html).

So it certainly needs to be part of the ongoing review which this approach favours (see 27th October 2010 blog: http://integrativecbt.blogspot.com/2010/10/continuity-and-collaboration-role-of.html).

Level 2:

This is the level of Problem-Solving.

Useful review questions on this level are:

What practical issues in the client’s life/environment may be in need of more attention than they are getting?

Does there need to be a review of goals? Of resources? Of motivation?

Are there skills such as assertiveness or relaxation that the client is in need of in order to move ahead?

Often this is the most important level to come back to when therapy doesn’t seem to be progressing. It may be that a clear sense of direction has been lost – goals, targets, strategies, commitments may need to be revisited, and even revised if necessary.

Level 3:

This is the level of Cognitive-Emotional Re-Learning.

Useful review questions on this level are:

What blocks to therapeutic progress have arisen at Level 2 which might suggest that particular vicious cycles may be in operation? Do any of them suggest a specific mental health diagnosis such as depression, an anxiety disorder, an addiction, etc?

What aspects of a cognitively-based case formulation need to be put in place/revisited?

Are there specific negative automatic thoughts or cognitive distortions in play that haven’t been identified yet? Specific safety behaviours?

Often what needs reviewing at this level is the case formulation, and sometimes what needs to come more clearly into focus is an “off-the-shelf” case formulation, in other words a diagnosis. Sometime the reason that clients cannot make the necessary changes at a problem-solving level, despite their best efforts, is that they are struggling within a particular pattern of vicious cycles between specific cognitions, behaviours and emotions; sometimes this pattern already has a name e.g. Social Anxiety, Depression, Alcohol Dependence. If this is the case, there will not be much progress until both client and therapist become clear about it.

Level 4:

This is the level of Schema Change.

Useful review questions on this level are:

Is it necessary/desirable for the therapeutic work to go deeper, to address schemas/core beliefs?

How clearly named are the relevant schemas/core beliefs? Would a Young Schema Questionnaire be useful?

At the very least, more explicit exploration and naming of schemas/core beliefs can help to pull together a coherent case formulation. Deeper healing and resistance to relapse can also come from more direct work on softening/diluting the power of maladaptive schemas – however, this is long-term work by its very nature, and clients may need to make a difficult decision about the trade-off between investing further in therapy, and getting on with the improvements they have gained.

Level 5:

This is the level which looks at Embracing the Human Condition.

Useful review questions on this level are:

What THEMAs (Typical Human Evolved Motivational Axes such as Mating, Status, Affiliation, Territory etc) are most relevant at this point in the client’s life? (See 25th March 2011 blog: http://integrativecbt.blogspot.com/2011/03/more-than-you-might-think-getting-to.html and Psychotherapeutic Naturalism blog 20th March 2011: http://psychotherapeuticnaturalism.blogspot.com/2011_03_01_archive.html).

Which of the client’s needs can perhaps be more fully met, and which ones are more a matter of adjusting their expectations to reality?

Does the client need to look more closely at the values/philosophy they hold, in order to get a clearer perspective on their larger goals?

Reviewing at this level can be surprisingly practical, and not as abstract as it might sound. There is very little point putting great effort into moving forward, if you aren’t facing in the direction in which you want to go!