Flexibility-Based Cognitive Behaviour Therapy

Insights from 40 Years of Practice

Windy Dryden

• Publisher: Routledge
• Year: 2018
• eBook ISBN: 9781351246408
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

In this book, Windy Dryden brings together the four major strands that have shaped his idiosyncratic approach to clinical practice – (i) Cognitive Behaviour Therapy; (ii) flexibility in practice; (iii) Rational Emotive Behaviour Therapy; and (iv) pluralism – an approach he calls 'Flexibility-Based Cognitive Behaviour Therapy'.

Perhaps uniquely for the literature, this volume provides an extended account of how a world-leading therapist personally thinks about and practices psychotherapy. As well as insights from over 40 years as a therapist, the book reflects the most the recent developments in Dryden's work, and highlights both the different theories he is using and the core building blocks of his practice.

Aimed at therapists in training and practice, Flexibility-Based Cognitive Behaviour Therapy presents a rare opportunity to gain an insight from one of the leading figures in the field of psychotherapy.

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Chapter 1

Rigidity and flexibility

Flexibility-Based Cognitive Behaviour Therapy (FCBT) is based on the concept of flexibility. To understand flexibility I would like you to consider its antonym, which is rigidity. By adopting a rigid approach to phenomena we end up with a fixed view about how such phenomena absolutely should or must be. We may take action to try to force these phenomena to fit into the fixed categories we have established in our minds, if they are not in any way as we insist in our mind that they must be.

1.1 Procrustes

Let me start by giving you an example from Greek mythology. A certain Procrustes had a house by the side of the road and offered hospitality and a bed for the night to passing strangers. He would invite them to dine with him and then to sleep the night. Procrustes was rigid in his insistence that everybody should fit into his one size fits all bed. Because he had this rigid view, he would stretch the legs of those guests who were too short for the bed and cut off the legs of those who proved too tall for it. All this was because Procrustes was rigid about having his guests fit into his bed. In fact, the phrase ‘fitting something into a Procrustean bed’ is derived from this story. But justice finally reigned: Procrustes had a dose of his own medicine when Theseus adjusted him to his own bed.

Now, let’s imagine what would have happened had Procrustes been flexible in his approach towards having guests sleep in his bed. First, he would have let them sleep in his bed without trying to ‘adjust’ them in any way. If he had only wanted people who fitted his bed exactly, he would only have invited people he knew would fit the bed. Moreover, he might have ordered different-sized beds to allow his guests to be comfortable. Had Procrustes done all this, Theseus would have had no reason to exact justice by killing him.

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The story of Procrustes – and my proposed alternative – clearly demonstrates the consequences of rigidity and flexibility. The rigid stance of Procrustes led to the death of his guests and eventually to his own death. He was unable to think of a creative way to solve his ‘bed-size’ problem and his rigidity led to ‘black and white thinking’: ‘Either you fit my bed or I will make you fit my bed one way or another.’ Had Procrustes adopted a flexible approach, however, he would have engaged in creative, lateral thinking, his guests would have lived and he would have lived. By being flexible he would have adopted a form of ‘grey’ thinking rather than ‘black and white’ thinking, as represented by the thought: ‘There are a variety of solutions to the problem if you don’t fit my bed.’

1.2 Rigidity and flexibility in psychological functioning

Procrustes’ story still has much to teach us both about psychological disturbance and how to address it. I will deal with each of these issues one at a time. First, I will examine the impact of rigidity and flexibility on psychological functioning.

Albert Ellis (1913–2007) was the founder of Rational Emotive Behaviour Therapy (REBT) and I have practised this approach, in my own way, for over 40 years. Ellis argued that psychological disturbance is based on ‘absolutistic’ thinking¹ (Ellis & Joffe Ellis, 2011) and that psychological health is based on ‘nondemanding’ thinking² (Ellis & Joffe Ellis, 2011). I have been deeply influenced by his views on this subject.

1.2.1 The impact of rigidity on psychological functioning

I will show what the impact of rigidity is on psychological functioning by providing an example. Sarah’s approach to achievement at work is rigid. If her work performance is good, she will be pleased as long as it continues to be good. However, although her performance is good, she becomes anxious if she thinks anything might prevent her achievements at work from continuing. Sarah’s problem started when her work performance deteriorated. At this point, she became disturbed psychologically because her attitude to achievement is rigid and therefore for Sarah the failure to achieve is not an option. However, the problem is that it is an option in reality. Therefore, as this reality began to occur, Sarah had no capacity in her mind to deal with it in a constructive way because of her mental rigidity. This rigidity led her to form one or more extreme conclusions, for instance:

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• ‘When I don’t achieve at work it’s the end of the world’ (which is known as an awfulising attitude).

• ‘Not achieving at work is something I can’t put up with’ (which is known as a discomfort intolerance attitude).

• ‘When I don’t achieve at work I’m a failure’ (which is known as a self-devaluation attitude).

When it came to her behaviour, Sarah’s rigid response to her non-achievement at work led to a dual response. Sometimes she gave up, while at other times she would redouble her efforts, thus risking her health through overwork. Which of these two paths she took depended, partly, on how her rigidity impacted on the type of extreme attitude she held and the inferential thinking it subsequently resulted in. Inferential thinking is characterised by interpretation and prediction, in this case coloured by rigidity. When Sarah’s rigidity caused her to think that non-achievement proved she was a failure (extreme, self-devaluation attitude) and that she would never succeed at work (subsequent inferential thinking), she was prone to give up. On the other hand, when Sarah’s rigidity caused her to think that her failure to achieve was not an option and that it should be avoided at all costs (extreme awfulising attitude) and that she would not allow anything to impede the achievement of her goals (subsequent inferential thinking), she would tend to overwork, putting her health in jeopardy. Sarah alternated between these two responses, depending upon how things were going at work and which extreme attitude and subsequent inferential thinking she was engaged in at the time.

1.2.2 The impact of flexibility on psychological functioning

I have emphasised that flexibility is the healthy alternative to rigidity. Let us examine how the adoption of a flexible approach to work achievement would make a difference to Sarah. If Sarah adopted a flexible perspective to work achievement, then if she performs well at work, she will be satisfied as long as she continues to perform well. She may become concerned (rather than anxious) if she thinks anything might threaten her work achievements from continuing. This concern will help her engage in productive problem-solving to prevent any threats that may be looming and to handle constructively any threats that may materialise. If Sarah’s work achievement ceased then her flexible mind would enable her to deal with this possibility healthily because, while it might be undesirable, she has not excluded the possibility of a lack of achievement at work from her mind. As such, Sarah would have the mental facility to handle it constructively. Her flexibility would enable her to make one or more of the following non-extreme conclusions:

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• ‘If I don’t achieve at work, it’s bad but it isn’t the end of the world’ (this is known as a non-awfulising attitude).

• ‘Although it is a struggle to cope with non-achievement at work, I can put up with it and it is worth my while for me to do so’ (this is known as a discomfort tolerance attitude).

• ‘If I don’t achieve at work I am not a failure. Instead, I am a complex, unrateable fallible human being who at the moment is not succeeding’ (this is known as an unconditional self-acceptance attitude).

Regarding her behaviour, in response to not achieving at work Sarah’s flexible standpoint will lead her to act in a number of ways. Compare this with the split in her response when she takes a rigid standpoint. If she is flexible she will first look for the source of her difficulty and then take remedial action based on a reasonable assessment of her problem. She may, for example, decide she needs to learn a new skill and in this case will enrol on an appropriate training course. Alternatively, she may decide that she has a personal difficulty that is preventing her from progressing. In that case she will take the appropriate steps to address this difficulty, by seeking counselling or coaching, for example, depending on the nature of the difficulty. She may also seek help from her workplace or decide that she should take steps of her own to get back on track. In other words, she has a variety of options, all of them designed to encourage her to handle the obstacle and allow her to improve her work performance. This approach contrasts with a black and white attitude in dealing with the problem stemming from a rigid mental attitude. In this later case, as you may recall, she will either tend to give up or to work in an unhealthy way to get back on track.

Sarah’s constructive responses are based on her non-extreme attitudes and her subsequent realistic inferential thinking. Both of these will arise from a flexible approach.

1.3 Rigidity and flexibility in the practice of psychotherapy

If you survey the whole field of psychotherapy, it will soon become clear to you that there are many different approaches. Specific approaches exist within the traditions such as psychodynamic, humanistic, cognitive-behavioural, transpersonal and systemic, as well as therapies that aim to combine or integrate these approaches. This way of working is known as eclecticism, psychotherapy integration or pluralistic practice.

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Concepts of rigidity and flexibility are relevant to the above areas. It is possible, for instance, to practise a specific approach to therapy either in a flexible or rigid way and my hypothesis is that experienced practitioners within these approaches are more flexible in their use of them than novice therapists who are more likely to practise their particular approach in a more rigid, by-the-book form.

Those practitioners who consider themselves advocates of eclecticism, psychotherapy integration or pluralism tend to view themselves as practising therapy in a flexible manner and this is probably the case to the extent that they show no commitment to any specific approach to therapy. However, if we take a closer look at the practice of the latter, it will soon become obvious that they do favour particular approaches over others. However, depending on the extent that they exclude specific approaches, one might well ask why they are excluding or downplaying these approaches. For instance, many training programmes devoted to integrative approaches to counselling and psychotherapy, either tend to exclude or downplay cognitive-behavioural elements. This seems strange considering that among the different specific approaches within psychotherapy, CBT has perhaps the best evidence base. Could this be a sign of rigidity? It is perhaps difficult to say, but to underplay or exclude an approach that has a good evidence base may suggest this.

1.3.1 What does it mean to practise an approach rigidly and flexibly?

Every psychotherapeutic approach has practical procedural rules. In REBT, therefore, a treatment sequence outlines a particular order in which interventions should be made (Dryden, DiGiuseppe & Neenan, 2010). In person-centred therapy, therapists are encouraged to work within clients’ frame of reference. Its practitioners are consequently discouraged from asking questions as these may come from the therapist’s frame of reference rather than that of the client’s.

When these rules are applied rigidly, an REBT practitioner would only adopt the recommended sequence even where there was evidence that this sequence was not working. In person-centred therapy, a therapist who never asks questions is considered to be rigid, particularly in cases where asking a question may progress the therapy. Thus, rigidity in psychotherapy occurs when practitioners adhere dogmatically to rules of procedure and exclude specific interventions that could be helpful even if not generally recommended by the particular approach.

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What, in contrast, are the markers of flexibility? Let me be clear: I do not equate flexibility in the practice of psychotherapy with being laissez-faire in the sense that anything goes. Neither do I mean that all approaches are given equal weight when considering eclecticism or integration. Those practitioners who favour specific ways of working, particularly when there is evidence in favour of these ways, are acting ethically by explaining this point to their clients. They are, however, being flexible by including methods in their practice they do not necessarily favour when it is indicated that they should do so. Therefore, practitioners are being flexible when they have preferred ways of working but are prepared to make compromises with their preferences.

1.4 The concepts of flexibility and rigidity in Flexibility-Based CBT

In this book, I use the phrase ‘Flexibility-Based CBT’ (FCBT) to describe the way I work for two reasons.

1 It asserts that flexibility is the basis of healthy functioning and that my goal is to promote flexibility in my clients – flexibility in cognitive functioning, in behavioural responding and in pursuing their goals and acting on their values.

2 I have used the term FCBT because it advocates flexibility in therapeutic response. As I see promoting flexibility in psychological functioning as a major goal, I therefore favour therapeutic techniques that advance this goal, but because FCBT is flexible as a major therapeutic principle, it enables me to make compromises with my favoured strategies and techniques when it is in my client’s interests to do so.

1.4.1 Is it possible to practise FCBT rigidly?

‘Yes’ is the short answer to this question. The founder of Rational Emotive Behaviour Therapy (REBT) Albert Ellis, whose ideas have greatly influenced my development as a psychotherapist, once said that any good idea can be turned bad by rigidity. So how may I avoid being rigid in the way I practise Flexibility-Based CBT (FCBT)? I think I can do so in the following ways.

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1.4.1.1 Guarding against imposing flexibility as a goal on a client who is not interested in it

A rigid approach to things is comforting for some clients, who don’t want to become more flexible. I would acknowledge, as a therapist, that in my opinion, the client would be better served by learning to become more flexible and I might make this case to the client. On the other hand, I would accept the client’s explanation and help them in the way they want to be helped provided this did not endanger the client’s life or well-being. I would not impose flexibility on disinterested clients.

1.4.1.2 Using non-preferred strategies and techniques and making compromises with my preferences

I begin by using techniques that best facilitate flexibility and I carry on with these techniques to give the client every chance to use them and to get the most out of them. However, when it becomes clear that the client is not benefiting from these preferred techniques I will stop using these methods. Rather than being driven by my allegiance to the ideal practice of what I call FCBT, I would be driven by my allegiance to the client. According to an apocryphal story, a trainee psychoanalyst once said: ‘The beauty of psychoanalysis is that even though the patient is not improving at least you have the comfort of knowing that you are doing the right thing.’ This viewpoint is anathema to me: as a flexible therapist, I object both to the smugness of this statement and to its rigidity.

1.5 Pluralism and Flexibility-Based CBT

As there are echoes of the concept of pluralism in what I have written in this chapter up until now, let me make clear the pluralistic roots of my practice.

1 What I call Flexibility-Based CBT belongs within the cognitive-behavioural tradition of psychotherapy. However, I am respectful of other approaches both within and outside this tradition. Respect of t...

Table of contents

• Cover Page
• Flexibility-Based Cognitive Behaviour Therapy
• Title
• Copyright
• Contents
• Preface
• 1 Rigidity and Flexibility
• 2 Effective Bonds in Therapy
• 3 Shared Views in Therapy
• 4 Negotiated and Agreed Goals in Therapy
• 5 Goal-Directed Tasks in Therapy
• 6 the Importance of Context in Fcbt
• 7 Working With Rigid and Flexible Attitudes and Mindsets in Therapy
• 8 Working With Extreme and Non-Extreme Attitudes in Therapy
• 9 The Change Process in Therapy
• Appendix the Models of Psychological Disturbance and Health That I Use in My Work
• Notes
• References
• Index