Fundamentals of Cognitive-Behavior Therapy

From Both Sides of the Desk

Carlton Munson, Bill Borcherdt

• Publisher: Routledge
• Year: 2014
• eBook ISBN: 9781317786221
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

A central premise of cognitive-behavior therapy is that individuals bring themselves to their emotions and behavior by how they think. Fundamentals of Cognitive-Behavior Therapy helps therapists and counselors address the important questions of cognitive-behavior therapy--what to ask, how to respond to difficult exchanges with clients, and why to make chosen responses--and helps them get at the cognitive base of clients'emotional disturbances more quickly. The book is unique in that it presents more than a textbook approach to problemsolving; it provides a wealth of data and philosophy that enables clinicians to respond more helpfully to client problems. Readers of Fundamentals of Cognitive-Behavior Therapy learn what therapeutic questions to ask and what responses to give to psychotherapy clients'common difficult questions and statements in ways that better contribute to the long-range happiness and survival of the client. This insightful book encourages therapists to help clients help themselves by showing therapists effective, detailed, responses that help clients answer their own questions and come to their own conclusions about why they react certain ways to specific situations. Among the 164 troublesome client questions and statements to which Borcherdt offers rational responses are:

• "But I don't feel like it."
  
• "I can't make a decision, because I don't know if it is the right one."
  
• "Why won't things work out for me?"
  
• "I can't help it."
  
• "I have so many problems and feelings that I don't know where to begin dealing with them."
  
• "Why don't I change? Why do I keep goofing up?"
  
• "Whose side are you on anyway?"Through this detailed look at the therapist's role in heightening client awareness of self, Author Bill Borcherdt, who has thirty years'experience as a therapist, provides a storehouse of practical, hands-on tact and tactics which encourages a problem-solving focus while preventing conversational drifting. He gives readers insights on:
  
• basic principles of emotional reeducation and well-being
  
• psychotherapy as teaching
  
• overcoming emotional disturbance tendencies
  
• getting individuals to answer their own questions so they can expose their own potential solutions
  
• understanding and overcoming clients'resistance to change
  
• a client-centered method of problem-solving interviewingThe book illustrates that the primary medium of the therapist's influence is funneled through both direct questions asked of the client and through the therapist's responses to client questions and commentary. Suggested questions and responses in the book help practitioners prepare for interviews and better understand clients'resistance to change. Designed for students in training as well as the beginning or seasoned practitioner, Fundamentals of Cognitive-Behavior Therapy includes 172 rational questions and 164 rational responses, each with commentary that shows the clinical justifications for asking these questions and offering these responses.Social workers, psychologists, guidance counselors, psychiatrists, nurses in mental health settings, marital/family counselors, alcohol and other drug abuse counselors, and other human service professionals will find Fundamentals of Cognitive-Behavior Therapy filled with practical and insightful guidelines for better helping their psychotherapy clients.

Section II.
Rational Rebuttals:
Fielding Client Curve Balls with Lesser Margin for Error

A Cognitive-Behavior Guide for More Efficiently Responding to Difficult Questions and Statements Frequently Posed by Clients

Introduction

This section attempts to illustrate tact and tactics for making the problem-solving interview process flow more smoothly. The therapist best not get bogged down in clients' methods of avoiding the issue of acceptance. This is a key dimension of client resistance-refusing to accept the reality that one is an imperfect person in an imperfect world, surrounded by imperfect people. Persuading clients to face the realities that "I'm not perfect," "Others don't have to treat me perfectly," and "Life doesn't have to be perfectly easy" form the foundation of Rational Emotive Behavior Therapy (REBT) as founded by Albert Ellis, PhD in 1955.

Typically in an active, direct, persuasive manner the REBT therapist attempts to teach clients how they can overcome their protest against reality, their refusal to accept what exists, and thereby minimize the effects of this tripod of emotional disturbance that places demanding, unrealistic expectations on self, others, and life. You would think that while being led into uncharted, more tolerant, rational waters clients would welcome with open arms ideas that have good potential to provide emotional relief. No siree! William Shakespeare said, "The whole world well knows, but nobody knows well." The whole world well knows that they don't have to be perfect, that others don't have to treat them perfectly, and that life doesn't have to make it easy for them to achieve their goals and accomplish their ends-yet, many are reluctant to know well. This tendency to look an emotional-control gift horse in the mouth is often highlighted in the resistance-to-change questions asked and the contrary statements made following solution proposal. These common progress-blocking questions and statements reflect clients' difficulties with their own hesitations and sidetracking. What these demotivating inquiries and procrastinating position statements commonly are, and examples of how they can be responded to in a way that extends the purpose of the helping session, will be identified.

Not that it is essential that you be as quick on your feet as a Philadelphia lawyer. But when your client throws you a curve ball, it can be helpful to have a wide range of response possibilities to draw from so that you don't strike out. But if you do strike out, you do! This text is not meant to perfectionistically imply that there is an ideal response to every tough client question/statement and that you have to find it. Rather, what is said is that though the perfect interview doesn't exist, you do, and that therefore there is room for your own creativity of response. Your problem-solving responses aren't required "to go by the book" or this book. It is hoped that narrative response possibilities identified by me will stimulate your thinking thus adding to your existing practice-theory by helping to field clients' murky questions and statements so that the most efficient paths in the problem-solving venture are taken. Sometimes it is helpful to piggyback off things that you already know that are stated in a different way. I suspect this is what part of this reading will accomplish.

Eleven Irrational Ideas

You are not required to have a therapeutic retort on the tip of your tongue for every therapy condition. To avoid bringing perfectionistic tendencies to your efforts to meet and beat client resistances, minimize the following irrational ideas that you might hold coming into the therapy. Each will put a strain on the problem-solving process and a damper on desired change.

• "I must have all the answers all of the time when my client questions the relevance of my ideas for him or her."
• "When clients position themselves in a way that discloses their opposition to my ideas I must (over) explain myself so as to win them over to my way of thinking."
• "There is an absolute definite, right, precise thing to say at each crossroads in therapy and I must find it in each and every instance."
• "I must always appear strong and confident to my clients and the only way I can do this is to at least appear to be Johnny-on-the-spot."
• "I, not the client, must take full responsibility for achieving the consensus and agreement absolutely necessary for successful therapeutic outcome."
• "When my clients don't understand me or agree with me I must become unduly concerned about it or else it might appear that I am not interested in them."
• "It is highly significant for me that I gain necessary approval from all my clients, and how can I do that if I am not always capable of rightly responding to all their contrary questions and negative statements in each and every instance that they present them?"
• "It is easier to avoid challenging clients' difficult questions and statements than it is to counter them, usually by agreeing with rather than disputing them."
• "My clients have no right to challenge my authoritativeness and experience on the topic and instead must obediently comply with my directives."
• "Because up until now I have deemed myself inadequate for responding to certain types of questions relating to certain types of problems, I could never learn to be more efficient in such matters in the future."
• "When I start to think about saying the wrong thing in the throes of client side-steppings and resistances, I must keep catastrophically dwelling on the worst possible occurrence."

Eleven Counter-Ideas

Each of these eleven irrational ideas can be countered with:

• "In an effort to neutralize my clients' resistances I hope to have some, if not many, of the answers to their questions. But, it is not an absolute necessity that I do so."
• "If I overexplain myself in the face of clients' doubtfulness, they will soon have me over a barrel."
• "Just as there is more than one way to look at things, so too are there varied guidelines, not recipes for responding to clients' tough questions and statements."
• "Perhaps modeling my own fallibility has more value than compulsively trying to appear strong and in control."
• "My clients and I have a joint responsibility for attempting to get the most out of therapy."
• "There is no universal psychotherapy rule that says my client always or ever has to agree with me or that I must unduly upset myself about our conflict of opinion."
• "Gaining my clients' approval is fine but if I focus on that I will likely lose sight of doing what would be better."
• "Overexplaining myself to my clients puts me in a dependent rather than in an interdependent relationship with them whereby I'm working for them, rather than we're working with each other."
• "If I just respond in ways that tickle my clients' ear, that might get them to like me, but will make it unlikely that they will learn anything from me."
• "Granted, up until now I haven't fared very well in managing my response to certain problem areas, but that doesn't mean that I can't learn from my mistakes and make fewer of them in the future."
• "Brooding about the possibility of putting my foot in my mouth will likely only unnerve me, making it more likely that I will fumble."

How to Handle Troublesome Questions and Statements

Each of the 164 listed difficult questions/statements frequently posed by clients is followed by a sampling of response possibilities from the therapist. Commentary about the implications of the question, i.e., the clients' motivation for asking it as it reflects the clients' belief system is included.

Seventeen Factors to Consider When Faced with Difficult Questions/Statements

Problematic questions/statements voiced by clients are often characterized and motivated by one or more of the following factors:

1. Low frustration tolerance (LFT)-Appealmg for an easier, surer, safer method of change is a tip-off of the holder's exaggerated view of the difficulty that is required to achieve a given result. The stronger the appeal, the lower the frustration tolerance and the higher the anguish. Pronouncements such as "it's too much to bear," "it's too risky," and "it's too much to tackle all at once" reflect resistance to change based on LFT.
2. Ego anxiety/fear of failure—When clients state "Wouldn't I be a failure," "What a fool that would make me," or "I would be to blame if something went wrong" they are defining themselves by the (rotten) fruits of their labor. This view of failure as shattering results in excuse making, denial, rationalization, and defensiveness, which serve as potent forces for blocking efforts to change.
3. Indecisiveness-When probabilities are not good enough replacements for certainties, clients will "reluctance" themselves out of the starting blocks of change. "How can I be sure that this is going to work?" "How do I know which decision is better?" "How do I know when I've considered all factors?" One of my clients stated after I asked him what his decision was going to be, "I'll give you a definite maybe."
4. An exaggeration of the significance of things-Dramatic views such as "Would that ever be a catastrophe!" "That would overwhelm me," and "It runs and ruins my life" display a flair for overreaction. Such cognitive explosiveness dampens personal development initiatives.
5. Difficulty accepting the inevitable—Hard work, discomfort, being slighted, and failure are but a few of the assurances of life. Notions such as "I can't accept that," "I won't admit I'm in error," and "Don't tell me it might not work out" indicate pills that are deemed too bitter to swallow.
6. Grandiosity-Reflections that imply anointed self-righteousness stray from self-responsibility realities. Statements such as "Because I've paid some dues it's time for me to get what I'm owed," "I should be the one who doesn't have to work so hard," and "I know my way is best and that is what eveiyone should agree with" give expression to this self-centered perspective.
7. Self-pity-"Woe is me-ism" is seen in the asking of impossible questions such as "Why me?" "What did I ever do to deserve this?", and "Why do bad things always have to happen to me?" When voiced in a whiny, nasal-nosed manner they provide a heavier reading of this self-sorry emotion.
8. Insecurity-Lacking confidence in self brings on a flood of worry and anxiety. Statements that move away from rather than toward goal setting include "I could never do that," "I can't bring myself to do something so different," and "My knees would just be shaking too much on such foreign soil."
9. A quest and demand for certainty—"Once I know for sure," "I must know for sure," and "I need to know exactly what is going to happen" are all commands that insist upon guarantees before plowing ahead.
10. Complaints about not knowing tomorrow's answers todays-"Assure me of a rose garden tomorrow because without such pacification I couldn't make it through today" is the cry of the person who insists on the ability to look and predict ahead of him/herself.
11. All-or-nothing thinking-"This way or that," "something is either right or wrong," "good or bad," "either I'm capable or I'm not," "life will improve or it won't," and "I will either feel happy or depressed" are examples of this way or that-type reasoning. The implication of such rigid alternatives is that "you, my counselor, must explain to me what side of the fence this dimension to my life under consideration is going to fall on."
12. Overgeneralization—Something bad labeled as "awful," "terrible," or "horrible"; defining something as good and then insisting that because it is to your advantage you absolutely have to have it; and thinking of the possibility of failing and then rating yourself as a "failure" in the event of same, illustrate overstepping the bounds of the original premise.
13. Disapproval anxiety-Hesitation that reflects overconcern about what others might think is seen in the statements "It all sounds good-but what will others think?" "I can't disappoint him/her," and "I couldn't stand it if they didn't like what I did."
14. Discomfort anxiety—"But I would feel too nervous," "I would feel like a phony," and "I would feel so out of character" reflect demotivation based on fear of one's own discomfort while goal seeking.
15. Conflict anxiety-"Whatever you do, don't rock the boat," "I'm too afraid that I might ruffle someone's feathers," and "I couldn't stand it if I disagreed and got his/her dander up" equal the philosophy of avoiding conflict at all costs.
16. Humor deficiencies-Emotional disturbance stems from refusing to accept grim realities while taking oneself too seriously in relationship to them. Statements such as "There's nothing funny about this," "I dare not laugh," "This is no laughing matter," and "Nobody better think this is funny" reflect an overly grim approach to life's hassles, too numerous to mention.
17. Demandingness—Perhaps the common motivational denominator that lies behind difficult questions/statements posed by clients is the tripod of cognitive and emotive insistances:
    • (a) "I have to be perfect (or else I'm perfectly worthless)."
    • (b) "You have to treat me perfectly (or else you're perfectly worthless)."
    • (c) "Life has to be perfectly easy (or else it's perfectly worthless)."
    Rational Emotive Behavior Therapy tries to identify and change these three basic demands of the human condition as they are reflected in the variations of difficult inquiries and position statements made by clients.

Typical Troublesome Scenarios

Now that we have identified the motivational background for these hard-to-manage question-and-statement curve balls, let's begin to identify what they are, and some of the irrational ideas behind them, while including suggested rational tact and tactics for directly and forthrightly responding to them in a way that does not disrupt the problem-solving process. Confrontation, persuasion, and vigorous disputation are key words in efforts to extend, rather than derail, therapeutic ambitions. Therapeutic objectives include confronting the clients about their efforts to get themselves off the responsibility-for-self hook; actively-directively persuading them to take on a philosophy of admittance and sustained effort; and assigning them vigorous disputation tasks of a cognitive, emotive, and behavioral nature that encourage if not implore them not simply to have "insight" into their avoidances, but to forcefully and repeatedly do something to unblock themselves from such hesitations. The suggested helper's response to seeming-change boycott and blockage are by no means the "right" or "only" manner of fielding clients' impromptu resistant two-step questioning and commentary, but are alternative means of doing so that will supplement methods you already use. Mark Twain said, "It takes me three weeks to prepare for an impromptu speech." This text is designed to help clinicians better prepare for the moment of reckoning when their client begins to confuse the self-development issue with seemingly bewildering, sidetracking questions and comments. Samples of these questions and statements followed by commentary and suggestions appear below.

1. "But I don't feel like it."
   Waiting for an alleged spirit to provide utterance can be a long wait. To wait on inspiration to the neglect of the perspiration that produces it results in marking time. This comfort-trap inkling provides a convenient rationalization for inaction. "Blending in with the woodwork," "cocooning," and "not coming out of the womb" are descriptions for this avoidant position and the unusual, peculiar sense of comfort that comes from deciding to put effort on hold. The trick is to force oneself to the task, and whether one feels like it is beside the point. Whether it be assertively saying "no," speaking out in a group, or seeking a promotion, the feelings of nervousness, strangeness, queasiness, and awkwardness that often accompany change can be taken with you. Developing a philosophy of discomfort that is compatible with mental health so as to better acclimate oneself to these personal development growing pains is the major surgery solution to "I-don't-feel-like-it-itis." Engaging in tasks associated with unpleasant feelings can be done "as if" one felt like doing so rather than halting on the brink of attempted completion until one magically gets up on the right side of the bed.
   Getting the client to acknowledge his irrational ideas, such as "I must feel comfortable," "There must be a more becoming time and way to go about this," "I can only do things when I'm in the mood," and "Feeling out of sorts about this matter is just too much to bear," while offering the following alternative responses in an effort to get the client to think, feel, and ac...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• Dedication
• Contents
• SECTION I. ASKING RATIONAL QUESTIONS AND GETTING THERAPEUTIC ANSWERS: A COGNITIVE-BEHAVIOR INTERVIEWING GUIDE
• SECTION II. RATIONAL REBUTTALS: FIELDING CLIENT CURVE BALLS WITH LESSER MARGIN FOR ERROR
• Index