I receive a number of enquiries asking whether I do CBT. CBT stands for Cognitive Behavioural Therapy which is an approach which places importance on the thought processes behind dysfunction in moods such as anxiety or depression. I tell people that no, I do not stick to a CBT formula as this would mean having to leave out huge elements of the therapeutic relationship and the way I work. I appreciate that some people would like to have the safe distance to challenge certain aspects of their way of being in a structured way, without going too deep, such as CBT offers. Indeed, CBT can be a useful stepping stone in the counselling journey. But I am unable to leave a huge chunk of myself, my knowledge, intuition and therapeutic tools out of my counselling work. So if somebody wants pure CBT I recommend that they see somebody who's work focuses exclusively on CBT.
Here are some elements of my work that a purely CBT
approach does not involve:
The relationship as a tool
The therapeutic relationship can be a microcosm of
the relationships the client has outside of the therapy room. Once trust and
mutual respect has been built then I can give my clients respectful and helpful
feedback about why they may be having problems with how they relate to others.
This can be about finding it hard to trust others, or assuming that people
think the worst of them. I use myself - my emotional reactions to the client,
in conjunction with what they tell me about their relationships with others.
This is not for the fainthearted therapist. A high degree of self-awareness is
required and I believe that therapists should continue to engage in their own
personal therapy, as well the clinical supervision (a professional
requirement). Some of the most successful counsellors I know engage in personal
therapy from time to time to enhance their professional work.
Emotional expression
Irvin D Yalom states that successful therapeutic
outcome depends upon there being cognitive and emotional elements of the
therapeutic relationship (see Group Therapy - Irvin D Yalom). This correlates
with what I know from looking at the work of Antonio Damasio - a neuroscientist
who writes extensively about the role of emotions in our lives. He states that
emotions are essential not only for survival but to help us make decisions. We
are wired to emote and if we bottle up those emotions then they stay with us.
What the mind denies the body remembers. There are books on this topic and two
that spring to mind are The Body Remembers by Babette Rothschild and The Body
Never Lies by Alice Miller (which I review here). So, expressing emotions during therapy
helps in a couple of ways:
Processing trauma - trauma
can be a huge life event such as abuse or a near death experience. Trauma can
also be due to other stressful events such as being diagnosed with chronic or
terminal illness, death of a loved one, divorce, loss of job etc. For me,
trauma is common in childhood. The trauma of being born for one (from
incubated, conjoined bliss to a rude awakening of separateness and sudden
onslaught of bright lights, crashing sounds and independent respiratory,
circulatory and digestive systems kicking in...). Sometimes we are unable to
express the emotions associated with a trauma as we may be in shock, or we may
have been in an environment where emotional expression was frowned upon or
simply not modelled to us (we learn from experience and from example). Eventually,
though, there may come a time when we are ready to express our emotions.
Sometimes this is triggered by an event which is some way accesses our
repressed trauma which causes it to resurface. Sometimes, we are
presented with the opportunity to deal with the past in the here and now and
relegate the traumatic incident to where it belongs, in the past, by finally
expressing those associated emotions in a safe environment.
We are wired to emote
- I see it so many times; clients who have depression and/or anxiety probably due to not being able to express their emotions. This usually
takes the guise of feeling uncomfortable burdening others with their problems.
Ironically, these are usually the most thoughtful and generous people who are
always there for others. But for some reason, it's not okay to take what they
give. They find it easier to burden me as it is a professional relationship and
I get paid to listen. Even then you may be surprised at how guilty a client may
feel burdening me. However, the work for me here is to try and help them to
understand that it's okay to be vulnerable and in time, to be able to express
that to trusted friends/family.
Emotions help us to learn
- it's all very well having cognitive awareness. Our thoughts are wonderful
things, but our emotions are not secondary to our thoughts - they are
intertwined. Furthermore, the engagement of emotions during learning helps us
to apply what we learn outside in the real world (read this neuroscience
paper, We Feel, Therefore We Learn for more
information).
I have had a few clients who have had a batch of
CBT before finding me. As I say, it can be a useful stepping stone until a client
wishes to go deeper. It has been fed back to me that their experiences CBT
dismisses the emotional element of being. It recognises that emotions are
affected by thoughts, but does not utilise emotions in the here and now, as a
therapeutic tool.
Creativity in therapy
Thoughts can be the bane of our existence if
they are negative and repetitive. Thinking about thinking - switching on
cognition is order to try and escape cognition does not always make an awful
lot of sense. I believe that sometimes we need to switch off our thoughts
processes and integrate a more natural way of living. I often recommend
mindfulness based activities such as meditation, yoga, pilates, martial arts
(see here for article on martial arts and psychotherapy).
These give us a break from our automated thought processes and help to reduce
anxiety and improve our brain's neuroplasticity (the brain's ability to change
and adapt, see here for definition).
Occasionally I use a creative intervention when the
client is unable to access their emotions and "switch off" their
negative thoughts. This may involve sandtray work (I rarely use it but it has
been very effective where I believe it is indicated - more information on this here), working with miniatures or stones or
visualisations. I often ask clients to try and write down the details of any
dreams as there is often rich work here. It amazes me how many have dreams the
night before therapy! Sometimes we work together using analogous language such
as describing the holding of emotions as filling a bag to bursting point.
Something I do as a matter of course now in my
work, with almost every client, is to "mindmap" the session. I take
notes during the session - jotting down pertinent thoughts of the client's
including their use of emotion words, and any revelations. I offer my client to
read the notes at the end of the session and, especially for the visual
learners, it can be a powerful way of consolidating the session. It is also
useful to refer back to these notes as the therapy progresses. Showing a client
a session map from a few months ago can really help them see how far they have
come. This probably does not clash with the CBT approach as such and is but a small
aspect of the way in which I work.
Yalom on CBT
"When a CBT therapist really gets
distressed, who does he go see? I just have a strong sense it's not another CBT
therapist. I think he wants to go out and search for somebody who's wise and
can help him explore deeper levels."
Yalom refers to a "maniacal need to
empirically validate everything you do" in an article published on Psychology Today, written by Ryan Howes. Ease
of measurement is perhaps the main reason why CBT is so popular with
institutions offering time-restricted therapy.
CBT and existential therapy
Finally, my work is based upon my personal
philosophy on life, which acknowledges the struggles with human existence. With
all the potential joys of life that we may be able to access, there is always
the knowledge that ultimately we will die, that we may struggle to find meaning
in our lives, and that sometimes we feel a deep sense of loneliness. Chasing
those thoughts away by replacing them with positive thoughts will not eradicate
those existential issues. Only in honouring and accepting our struggles can
we find relief and a sense of not-alone-ness. I would find it hard to leave
that part out of my work.
Amanda Williamson is a registered member of the BACP with a thriving private practice in central Exeter, Devon
Amanda Williamson is a registered member of the BACP with a thriving private practice in central Exeter, Devon
4 comments:
Touche. Sound arguments. Keep up the great spirit.
Here is my website - web page ()
Shouldn't you be more concerned with what the empirical evidence shows instead of your "feelings"? Doesn't seem ethical to dismiss a proven treatment because of your feelings.
I would argue that it is inappropriate to comment without actually reading the article, in which I clearly state that I use elements of CBT rather than 'dismiss' it as you state.
I love this! Very thought provoking...and thank you for the additional references so I may explore further. As a counseling student, I truly appreciate these posts.
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