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 12^th 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 27^th 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 25^th March 2011 blog: http://integrativecbt.blogspot.com/2011/03/more-than-you-might-think-getting-to.html and Psychotherapeutic Naturalism blog 20^th 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!

Comfort Zones – How Much of our Lives Consist of Safety Behaviours?

The concept of Safety Behaviours (or Safety-Seeking Behaviours) is a familiar one to those working with anxiety from a CBT perspective.

According to David M. Clark (1999),

Salkovskis (1988, 1991) defined a safety-seeking behaviour as ``a behaviour which is performed in order to prevent or minimise a feared catastrophe'' and suggested that such behaviours often explain why the non-occurrence of a feared event fails to change patients' negative beliefs. For example, in the case of cardiac concerned panic patients, he suggested that they continue to think that they might die in a panic attack because every time they have panic attacks, they sit down, rest, slow down their breathing or engage in some other safety-seeking behaviour and believe, erroneously, that performing the behaviour is the only reason they did not die.

Clark goes on to give the following examples of safety behaviours associated with a patient's fear of blushing. First he describes the feared outcome, then the safety behaviours intended to prevent that outcome:

``My face (and neck) will go red.''

Keep cool (open windows, drink cold water, avoid coffee, wear thin clothes).

Avoid eye contact. If in a meeting, pretend to be writing notes.

Keep topic of conversation away from `difficult' issues.

Tell myself the man isn't really attractive; ``He's no more than a 2 (out of 10) for attractiveness''.

``If I do blush, people will notice.''

Wear clothes (scarf, high collar) that would hide part of the blush.

Wear make-up to hide the blush.

Put hands over face; hide face with long hair.

Stand in a dark part of the room.

``If people notice, they will think badly of me.''

Provide an alternative explanation for the red face; e.g. ``it’s hot in here'', ``I'm in a terrible rush today'', ``I'm recovering from flu'', etc.

The key disadvantage of safety behaviours, of course, is that they prevent disconfirmation of catastrophic beliefs, by making sure that they don’t get tested against reality. We never find out what would happen if we didn’t cover up the blush, if we said what we really think, if we drank from a cup someone else had touched.

Over their lifetimes, anxiety sufferers often engage in broader strategies of safety-seeking, which simply become part of their lifestyle. A socially anxious person, for instance, may choose their hobbies, their friends, even their spouse, in a way which is designed to protect themselves from social danger (i.e. negative judgment). Their hobbies may be solitary, their friends may be undemanding and task-oriented, their spouse may be happy to mostly stay at home and to concentrate on the domestic side of their lives.

Joining a religious group may also be a tempting safety-seeking strategy for some people, as there is usually a strong focus on group-belonging, and on directing negative judgments at people outside the group rather than within it.

The workaholic high-achiever, to take another example, seems to have found a way to guarantee positive rather than negative judgments from their peers. Of course, like all such strategies, this tends only to work in the short-term, bringing other problems in the longer-term, such as damage to family relationships, burnout etc. On the other side of the coin, the stay-at-home example above may also lead to its own negative career consequences, due to poor social networking skills etc.

There is food for thought here: to the extent that any of us are socially anxious and feel the need to ward off negative judgment, how much may we have built our lifestyles around this need?

Finally, widespread safety behaviours can also be found outside of these more individual examples. Superstitious behaviours, which are very common in most human populations, are classic examples of safety behaviours: touching wood is definitely ``a behaviour which is performed in order to prevent or minimise a feared catastrophe'', as is avoiding the number 13, and so many other everyday superstitious behaviours.

Perhaps the concept of Safety Behaviours needs to be a familiar one to all of us, and not just those working with anxiety…

References, further reading

Clark, D.A. & Beck, A.T. (2009) Cognitive Therapy of Anxiety Disorders. New York: Guilford Press.

Clark, D.M. Anxiety disorders: Why they persist and how to treat them. Behaviour Research and Therapy 37 (1999)

Vyse, S. A. (2000) Believing in Magic: The Psychology of Superstition. USA: OUP.

More Than you Might Think – Getting to Know Cognition Better

Judith Beck (1995, p. 1) defines the Cognitive Model of emotional disorders as follows: “…the cognitive model proposes that distorted or dysfunctional thinking (which influences the client’s mood and behaviour) is common to all psychological disturbances.”

There are many misunderstandings about the role of cognition in psychotherapy, for example:

The notion that cognition is disconnected from emotion. The reality is that, except in the case of specifically abstract thought, they are intimately connected – think of the panic that instantly accompanies the thought/belief “I’m having a heart attack”.

The notion that working with cognition is somehow optional in psychotherapy practice. In fact, given that the term “cognition” refers to something very central to human experience, namely the constant processing of information that informs our responses to our world, it should feature very strongly as a focus for therapeutic change. As Aaron Beck has remarked, "If beliefs do not change, there is no improvement. If beliefs change, symptoms change.” (American Psychological Association, 108th Convention, Washington DC, August 4-8, 2000).

However, the misunderstanding I mainly want to explore in this month’s blog is the idea that cognition is superficial and shallow. The truth is that it is deep and multi-layered; below I describe the various layers where we can see cognitive processes acting.

The most basic level of information-processing is the matter of where we direct our Attention. We are only cognitively and emotionally affected by a particular aspect of our environment to the extent that we notice it, pay attention to it. A socially anxious person, for instance, tends to notice and attend to the expressions on people’s faces, scanning for any possible signs of disapproval; an alcoholic notices where the drinks are kept.

A particular focus of attention such as the above can then trigger relevant Self-talk/Automatic Thoughts. The socially anxious person might be thinking “They don’t like me, maybe I said something stupid”; the alcoholic might be thinking “I’ll never get through the evening without a drink.” Aaron Beck describes his discovery of Automatic Thoughts which “…appeared to emerge automatically and extremely rapidly…prior to experiencing the emotions” (1976, p. 33). Such automatic thoughts, which clients are normally unaware of, but which they can be trained to become more aware of, make sense of the troublesome feelings which immediately follow them. The socially anxious person’s automatic thoughts (ATs) will make them more anxious and self-conscious; the alcoholic’s AT’s will increase their craving.

However, we don’t all have the same ATs about the same situations, so our individual ATs must be influenced by certainly underlying Assumptions/Rules. These are less accessible to present-moment phenomenological awareness than ATs, but can be deduced from the way we habitually respond to situations, cognitively, emotionally and behaviourally. For instance, if the socially anxious person tends to agree with everything that other people say (like the Paul Whitehouse character in the 90s BBC TV sketch comedy “The Fast Show”), we can deduce that amongst their underlying assumptions/rules are things like “no one must dislike me” and “no one will dislike me if I don’t disagree with anyone.” Typical human Cognitive Distortions such as Emotional Reasoning, Black-and-White Thinking and Catastrophisation are also found at this level.

At a deeper level again we find our Core Beliefs/Schemas, as described in a previous blog (“A Client with a Past: Schema-based Case Formulation” - 2 June 2010):

Our earlier learning experiences leave us with deeply held ways of viewing the world, ourselves, and others, ‘templates’ through which we process current experience, and which therefore tend to be self-perpetuating and rigid in nature... These templates can be called Schemas; their contents (e.g. “I’m unlovable”, “Men can’t be trusted” etc) can be called Core Beliefs.

Core Beliefs are more unconditional than Assumptions, as the examples above show.

And finally, in a recent blog on Evolutionary Psychology at

http://psychotherapeuticnaturalism.blogspot.com/2011/03/trials-and-themes-what-makes-humans.html

I discussed the concept of “THEMAs”:

Evolutionary psychology sees human life, like that of any organism, as consisting of strategic attempts to maximise our success along various key axes, such as mating, care-giving, satisfying appetites etc… There is no definitive list (yet) of these motivational axes, but I have put together a list for myself for practical use in the therapy context, which probably covers the main areas… I find it useful to call these major themes in human life “THEMAs” (Typically Human Evolved Motivational Axes). Themas can be seen as analogous to schemas, but operating at an even deeper level, in the way that they structure our lives without us being aware of the fact most of the time. Schemas operate at the level where we are not generally aware how much they structure our experience as individuals. Themas operate at the level where we are not even generally aware how much they structure our experience as a species.

… I list below what I see as the main Themas using the mnemonic “PASTMARKS”.

Parenting

Attachment

Safety

Territory

Mating

Affiliation

Reciprocity

Kinship

Status

So there may be more to cognition than meets the eye – hopefully this has given you food for thought!

References

Beck, A.T. (1976) Cognitive Therapy and the Emotional Disorders. New York: International Universities Press.

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

Using Language for Leverage: Metaphors in Integrative CBT

Metaphors are something we all use in our communication, to describe, to convey subtle meanings, to give a different perspective on something, and they are therefore found in all approaches to psychotherapy. We would expect them to be particularly central to CBT, as it is fundamentally about clarifying and changing views, perspectives and meanings. The cover of a recent book by Stott. R., et al (2010), Metaphors in CBT: Building Cognitive Bridges (Oxford: OUP), puts it well: “The business of Cognitive therapy is to transform meanings. What better way to achieve this than through a metaphor?”

For more information on this book see

http://www.amazon.co.uk/Oxford-Guide-Metaphors-CBT-Behavioural/dp/0199207496/ref=sr_1_1?s=books&ie=UTF8&qid=1290151525&sr=1-1

There are many examples of metaphors which we all use in therapy, both deliberately and unconsciously. To get a feel for some of them, we can look at them in the context of mental health problems such as depression, anxiety and addiction (further below I will explore metaphors in the context of the 5 levels of Integrative CBT).

Depression

Some metaphors commonly used by both client and therapist to convey the lack of reward and motivation experienced in depression are:

“Swimming through treacle”

“Living in darkness”

“Carrying a heavy weight”

“Being surrounded only by cold, no sign of warmth, endless winter”

“Digging yourself deeper into a hole”

“Turning your face away from life”

“Letting go of the grip you have on the ledge”

The last three are relevant for understanding the self-perpetuating nature of the problem, and for indicating possible ways out, i.e. by not digging, but turning around, by hanging on until help comes…

Anxiety

In talking about anxiety and fear, the metaphors will naturally be threat-oriented and risk-oriented, for example:

“Like living in a war zone”

“The burglar alarm is too sensitive, always getting triggered”

“Always on red alert”

“On stage, under the spotlight”

“Feeling paralysed, unable to make any moves”

The challenge for the client, in the context of metaphors like these, is to lower the level of alert, ignore and eventually recalibrate the burglar alarm, and learn that, even though life will always have risks and threats, the war is over.

Addiction

The experience of addiction has of course many metaphors attached to it:

“The monkey on your back”

“Selling your soul to gambling/alcohol/porn etc”

“Being eaten away by addiction”

“Living in the shadows”

“A garden being overgrown by weeds”

The good news, of course, is that addicts can gradually come out of the shadows, start pulling up the weeds and planting something better, and even reclaim their soul.

We can also look at the metaphors we use when discussing the process of therapy with our clients. While we may be comfortable with professional language such as “Behavioural Experimentation”, clients usually relate more easily to more everyday language such as “Reality-testing”, or better still to metaphors such as “Sticking your toe in the water”.

For the therapeutic process in general, we use images such as

Building a house - digging foundations, putting up walls and roof

Gardening - weeding, planting, watering

Sports injury - rest, physiotherapy, small steps

More specifically, we can look at what metaphors might be useful in discussing the 5 levels of the Integrative CBT model:

Level 1: Therapeutic Relating

Creating a safe space

Holding

Unpacking our baggage

Leaning on someone else for support

Creating the best conditions for growth, like with a plant

Level 2: Practical Problem-Solving

Putting petrol in the car

Making a map of the territory

Getting a clearer picture of where we want to get to

Checking our stock of resources for the challenge ahead

Profit and loss account in relation to motivation for and against change

Checking whether our investments are still worth the effort, cutting our losses if necessary

Level 3: Cognitive-Emotional Re-learning

Stuck in a rut, going around in circles

Opening the bonnet to see what’s happening inside

Untangling knots in our thinking

Looking at the bigger picture

Getting out of our own way

Reclaiming lost territory

Getting back up on the bike

Experimenting with a different style of serve, golf swing etc

Level 4: Schema Change

Seeing life through coloured glasses

Digging deeper

Undergoing an operation

Checking our operating systems for bugs

Scripts, models, programmes etc

Acting out old scripts (including between client and therapist)

Schemas as committee members – some may have a loud voice, but they only have one vote each

Level 5: Embracing the Human Condition

Human life as a journey

Challenges as adventures

Climbing a mountain – hard work, but great view, best not done alone

All in the same boat

And finally, the weather! – it comes and goes, we can’t influence it, only prepare for it

There is no doubt that such metaphorical language benefits both therapist and client, adding a richness and energy (more metaphors there) to the therapeutic dialogue, which can then be harnessed (and again!) for positive change.