25 March 2013

My struggles with CBT

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.

My training included CBT and REBT - Rational Emotive Behaviour Therapy (in my opinion more rounded and deeper than CBT as it involves core beliefs - not just the symptomatic thought processes. See this link for my blogpost on REBT vs CBT). I am an integrative counsellor with an emphasis on relational depth, The choice of therapeutic approaches I use is coherent with my humanistic outlook (please see My approach for further details). My baseline approach in the therapy room is Carl Rogers' person-centred therapy which places the importance of the relationship between client and therapist as the indicator of a positive outcome. I use elements of CBT, although I don't refer to them as being 'CBT techniques" - they are simply facets of a highly complex service that I offer to my clients. Challenging thought processes is an important part of the work, but is not the main emphasis.

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





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