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Section I
Foundations
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Introduction
Some key concepts
Doing therapy from the inside out
The approach introduced in this book, Comprehend, Cope and Connect or CCC, does not add intriguing new complexities to the task of doing therapy. We are rather in sympathy with the idea that the last thing the profession needs is yet another fancy branded therapy. Much of what is covered here will be familiar, even commonsense and obvious. The CCC perspective is achieved by by-passing some of the unnecessary layers of complexity that have crept into therapy practice because they were the route by which the founding fathers and mothers of our profession arrived at their conclusions â a bit like incorporating the scaffolding into the completed building. The key to arriving at this pared-down perspective is to view the enterprise from the inside out. This means starting with the raw experience that drives the behaviour that causes problems for the individual seeking help (or for those around them).
The word âencounterâ is not used lightly. To work at this level is to meet the human being in the room â not a set of symptoms, or a diagnostic classification. An encounter occurs between two people; two human beings. These two human beings will have much in common, and it is only that shared humanity that gives us access to the inside perspective, the starting point. Of course, from the foundations of humanistic and person-centred therapy, empathy and the communication of empathy has been identified as the foundation for effective therapy. The idea that the human relationship is key to supporting someone through the difficult road of unpicking old ways of approaching life and adopting new ones is fundamental to all therapy. The difference is that in other forms of Cognitive Behaviour Therapy (CBT), it has sometimes been seen as an important ânon-specific factorâ that should roughly look after itself. In CCC it is given a central role in the Comprehend section of the therapy, the formulation which informs the whole enterprise. The formulation starts by encountering the individual at the level of felt sense.
The selfâself relationship
This encounter is challenging for the client as well as for the therapist. Integral to the therapeutic encounter is the meeting between the individual and themselves and their feelings. As other approaches such as Acceptance and Commitment Therapy (ACT) and Compassion-Focused Therapy (CFT) have noted (Hayes, Strosahl & Wilson, 1999; Gilbert, 2005), avoidance of emotions lies at the root of many issues reported as âmental health problemsâ. CCC recognizes that the individual has good reason for this avoidance â the emotion feels intolerable, unbearable. However, the road to a fuller life and more complete realization of someoneâs potential requires facing the emotion and learning how to manage it differently.
Improving the selfâself relationship lies at the heart of any therapy, whatever the modality. When training staff in acute services, I would ask: âHow are the people who enter your service treating themselves?â The answer came easily: they were trying to kill themselves, or attacking themselves physically in non-lethal ways; they were neglecting themselves and their basic needs such as food and self-care to a dangerous extent, or recklessly dosing themselves with mind-numbing substances. In primary care or community services, the selfâself relationship is not normally as violently hostile, but users of the service tend to mete out to themselves treatment that would be unthinkable towards a good friend. Many people are simply trying to escape from themselves because meeting themselves feels unbearable. Encouraging them to turn round and encounter themselves is challenging but rewarding. It is the only route to real change. The therapist must not underestimate that challenge.
Felt sense
The key concept of felt sense, which registers the unbearable feeling, needs to be thoroughly grasped in order to follow this approach. The only way to define it is through experience, so you are invited to follow this simple exercise:
Bring your attention to the present moment, to your physical presence and surroundings.
Ask yourself: What does it feel like to be me, here, now?
Are you comfortable, at ease with yourself?
Are there background anxieties, sadnesses, impatience? Your body will signal these in the form of tension, unease in the stomach, etc.
Hopefully you are currently in a calm space (and alert). This will not always be so.
Think of times when you have had bad news, a horrible day at work, a row with someone you love.
What does it feel like to be you at such times?
The knowledge and the contrast you will hopefully have grasped through this exercise lies at the heart of the CCC approach. Its importance comes from the rather obvious reflection that people are prompted to seek therapy by noting that what it feels like to be them most of the time is uncomfortable, uneasy, frightening, desperate, despairing or whatever. Such feelings lie at the heart of a poor selfâself relationship.
Alternatively, they might come into therapy because the way in which they manage that horrible feeling inside (drinking a lot of alcohol, being reluctant to get out of bed, etc.) is itself causing problems. This coping strategy-based Âperspective cuts through the whole apparatus of diagnosis and illness talk to engage with the struggling human being at the heart of it. That human being is feeling awful and trying to do something about it; finding ways of coping which work well in the short term (drinking too much or not getting out of bed are natural responses when things feel unbearable) but cause yet more problems in the medium to long term. This is an all-too-human experience that anyone can recognize in a small way, on a bad day.
The limits of straight empathy
This is a normalizing rationale and seeks to do away with the âthem and usâ, âill and wellâ distinctions prevalent in conventional mental health discourse. However, there are dangers in seeking to apply the âit is the same for everybodyâ argument uncritically. As hard-pressed nursing assistants on a ward full of challenging individuals often point out, they have had to put up with some difficult events in their lives too; there have been times when things went seriously badly for them. They know how difficult it can feel, but then they pulled themselves together and got on with it. Why then does âxâ in room âyâ have to tie a ligature every time things get on top of her? OK, she had a horrible childhood, but that was a long time ago.
The answer leads into the complexities of the way in which the human brain is wired up, which result in past threat being experienced as present. In extreme cases, it feels as though the past is happening now, as in flashbacks; in less extreme cases, past and present are more subtly entangled in a way that impacts mood and judgement. Recognizing and normalizing this peculiarity of human hardware is central to the formulation at the heart of the approach. Taking into consideration the impact of this âpast experienced as presentâ in understanding the way in which the individual is reacting to present adversity, enables the therapist to reach after a more accurate appraisal of the felt sense behind the behaviour.
The true challenge of what it feels like to be that individual can only be gauged by the way in which they manage their internal felt sense. The nature of the trauma or other events documented in the history will provide important clues, but each individual arrives at the point where they meet you through a unique combination of events. Some of these will be recorded; others not; and others were simply too subtle to get noted, but are no less impactful. Their own sensitivity and temperament is a further essential ingredient in the mixture. There is no easily applied formula that will predict or explicate this individualâs internal world.
Ways of knowing
The preceding discussion rests on an assumption that needs to be brought out into the open. This is the notion that human beings have access to two very different ways of knowing about the world, both internal and external. In one sense these two ways of knowing are complementary in that we constantly use both without thinking about it, but in another, they are as different as chalk and cheese. The problem is that our society privileges one of these and tends to ignore the other. Objective, experimentally verifiable, scientific knowledge is accepted as the gold standard, and it is this that dominates the research, the education system, the text books. Psychology and therapy has sought the safe, academic respectability of privileging this way of knowing.
However, it is knowing by experience, by feeling, that actually rules our lives. Really important things to do with relationships and the status of the self are registered as feelings. Decisions about, say, who not to trust and who to spend our lives with are determined experientially. This way of knowing is obviously crucial for therapy. The earlier discussion in this chapter on felt sense signals that CCC gives pride of place to experiential knowing, while acknowledging that there can be absolutely no progress without the two working together. Easy collaboration between the two is the assumed norm, but cannot be taken for granted. Along with healing the selfâself relationship, facilitating smooth working between the two ways of knowing has to be central to the enterprise of therapy (think âreflective spaceâ). Mindfulness has been shown to be an extremely direct and accessible way of achieving this intercommunication, and, along with other third wave approaches to CBT, CCC places mindfulness at its heart.
Having given pride of place to experiential knowing, we are now ready to embark on the book proper. This will start by turning to the other, scientifically verifiable, way of knowing, in order to unpack what lies behind this split in human cognition and to place CCC within the theoretical map of related therapy approaches.
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Chapter 1
Introducing the therapy and integrating the third wave
The therapy
Before plunging into theoretical underpinnings, this chapter starts with a brief introduction to the bare outline of a CCC therapy, which will be covered in much more depth later in the book. This is followed by extracts from an interview with someone attending for a follow-up appointment, after having gone through the full programme, to give a sense of its impact â what it feels like from the inside!
Whether delivered in an inpatient or acute setting, in an outpatient psychotherapy service, or primary care, a CCC approach always starts with listening to the personâs story. Something will have happened or changed to bring them to seek therapy, or to be referred for it. These circumstances need to be attended to.
Usually at the second session, but even sometimes at the end of the first, the therapist starts to pull this information together into a formulation diagram, in close collaboration with the individual. This diagram starts with the feeling at the heart of the problem, on the assumption that whatever is unmanageable in this case, or whatever drives behaviours or avoidance that leads to problems, is an understandable response to a horrible and persisting feeling. The way the feeling is drawn as a misshapen object gives the formulation its name of âspikey diagramâ. Figure 6.6 shows a clinical example of a completed diagram. Circumstances leading to this situation are named in boxes, as the past and more recent triggers are highly significant, but not to be dealt with just now. Strengths, containing factors such as good relationships and faith, and a sense of that personâs potential, are named in a bow over the top. The maintaining vicious cycles are then worked out, as the sort of behavioural analysis that is central to all good CBT, but with emphasis on the way that these cycles both arise out of and continue to feed the central unbearable feeling.
This generally leaves the individual feeling understood; their emotions and ways of dealing with them have been validated, but at the same time, they can see how that way of dealing is keeping them stuck. This leads the way to a conversation on how to break the cycles, to face rather than avoid the feelings, and so take back charge of their life.
The means of breaking the cycles are often straightforward and practical. The individual might be happy to go off and manage them for themselves. They do not necessarily need regular meetings with the therapist who did the formulation, as often others can provide necessary support. This is where the flexibility of the approach comes in. It lends itself to distributing psychological skills, psychological thinking and ways of making sense of mental health problems throughout a team. In acute teams and inpatient settings, this offers the possibility of influencing the whole milieu in a more holistic, psychologically minded direction. In outpatient psychotherapy, the formulation devised with an individual therapist has been followed by group work or a course, designed to teach precisely those skills that are most often useful for breaking the vicious cycles.
The inside perspective
That is the description from the outside. For the inside view, I am indebted to âAmandaâ (who later appears in a case example in Chapter 9), who allowed me to record and use extracts from a brief interview with her on how she found the experience of a CCC therapy that linked the four formulation sessions with attendance at the twelve-week group programme. This is the programme that forms the content of Chapters 7, 8 and 9.
Of the impact of the therapy as a whole, Amanda said:
It changed my perspective. Instead of looking outwardly, I looked inwardly, and I have started to question myself; questions I would not have thought of asking myself about my feelings; about other peopleâs reactions and how they coped with things. Because of the attack, it made me insular. I was carrying that around with me, like a bag of something bad. I stopped looking back, at the negative, and started looking forward and moving on in a positive way. I stopped beating myself up all the time and have grown real self-respect.
On the formulation sessions, Amanda said:
The diagram blew me away. It put it in front of me how I was dealing with things. It is the cycle that you have to break. It made me really emotional. A eureka moment. Now I knew I needed the tools to get out of those cycles.
On the group experience, she said:
It was tough and challenging; faced with a lot of people you have not met before. You donât know their business and they donât know yours. It was a short period of time but very intense and a good outcome. The group makes you learn that other people are going through the same; other people are struggling. I am not alone. We can do it. We can support each other and share. You donât have to share your personal information. That is personal to you.
After that brief introduction to the therapy, from both sides of the fence, it is time to address the theory behind this apparently simple exterior.
The levels of processing problem
In the Introduction, the distinction between experiential and rational knowledge has been emphasized. There is general awareness of some sort of split within human cognition, given greater or less prominence, in most varieties of therapy, including CBT. The need to achieve reflective space, the ability to think about feeling, has already been mentioned. This is captured by Ellis (1962) in his distinction between inference and evaluation, usefully translated into âhot and cold cognitionâ. Other expositions have been less transparent. Power and Dalgleishâs SPAARS theory of emotion (1997), Roedigerâs conceptually and data-driven processing (Roediger, Gallo & Geraci, 2002), Wells and Matthewsâ (1994) S-Ref and Mansellâs Perceptual Control Theory and the Method of Levels (Mansell, Carey & Tai, 2012) all address the same issue with varying degrees of complexity and comprehensiveness. Brewin, who, with his team, has done important research on memory, distinguishes between verbally accessible and situationally accessible memory (VAMs and SAMs) (Brewin, Dalgleish & Joseph, 1996). Gilbertâs (2005) three-brain system is focused on social cognition.
In essence, all these theoretical frameworks are homing in on the evident gulf between the sort of fast track processing associated with response to threat and a more considered appraisal of the wider picture. Ellisâs âhot and cold cognitionâ (Ellis, 1994) captures the role that the body plays in this distinction. Fast track processing is driven by high arousal, the sympathetic nervous system; cool consi...
