Overcoming Obstacles in CBT

Craig Chigwedere, Yvonne Tone, Brian Fitzmaurice, Michael McDonough

• Publisher: SAGE Publications Ltd
• Year: 2011
• Print ISBN: 9781849206167, 9781849206150
• eBook ISBN: 9781446292594
• Edition: 1
• Topic: Psychology
• Subtopic: Cognitive Psychology & Cognition
• Index: Psychology

While many textbooks explain the techniques of CBT, few fully explore the issues surrounding their application in real-life practice. This unique book comes to the rescue of anyone struggling with the challenges of practising CBT, whether you are a trainee working under supervision or a qualified practitioner. It examines key obstacles, issues and difficulties encountered over the course of the therapy, illustrated with extensive case examples. Learning objectives, practice exercises and further reading lists help you engage with and relate the issues to your own practice.

Acknowledging that people are more complex than just the presenting disorder, the authors consider questions around:

o Good practice in assessment and case formulation

o The challenge of diagnosis

o Key client issues, such as guilt and shame, perfectionism, and inability to tolerate storing feeling

o The therapeutic relationship

o Organisational factors.

This succinct and accessible guide throws a lifebelt to any CBT trainee or therapist struggling under the realities of today?s psychotherapy and counselling practice, particularly within NHS settings.

1

INTRODUCTION

CRAIG CHIGWEDERE, YVONNE TONE, BRIAN FITZMAURICE AND MICHAEL MCDONOUGH

 

Standard cognitive behavioural therapy (CBT) texts are generally organised around specific disorders with the emphasis on commonalities within those disorders. This is effective when the presenting problem ‘fits’ neatly into the model and when the patient engages well with therapy and the therapist. This is not always the case. Practising clinicians, trainees and teachers are aware that therapeutic work frequently becomes derailed or stuck at various stages of the process. The likelihood of successfully achieving therapy outcomes is then impeded, causing frustration, distress and confusion for both therapists and those seeking help. Obstacles to progress often connect to recurrent patterns and themes, general and specific, which are embedded in the therapy process.

Therapy is about overcoming difficulties. Therapists and supervisors are therefore routinely challenged to understand and negotiate a wide range of therapeutic obstacles. Cognitive behavioural (psycho)therapy is an established psychotherapeutic modality, with an unrivalled empirical evidence base. It continues to be driven by theorists, researchers and clinicians with a desire to work through evidence-based treatments with clients. Whilst acknowledging the evidence base of CBT and its undoubted importance there is much to be gained from sharing tales from the therapy room.

THE ART OF CBT

The less researchable principles of CBT practice are often omitted in the dissemination of CBT literature. CBT is viewed by some as a simple set of tools, used to superficially tinker with the client’s problem. This is often put forward as a criticism of CBT. As professionals, we are all aware of the dangerous potential of insufficiently trained and supervised individuals who having read a CBT manual believe themselves to be knowledgeable and competent enough to apply it in therapy with clients. In contrast novice therapists may believe themselves to be ineffective, when the protocols and techniques that are outlined in a book do not yield an expected outcome. The unseen intricacies that gel CBT into an effective therapy are not often readily apparent. The therapeutic journey is paved with obstacles. The established protocols prepare the therapist for impasses along the way but many arise unexpectedly. Negotiating these obstacles is a central challenge for supervision and therapy. It is therefore of great importance that clinical experience from the frontline offers a valuable contribution to the ongoing evolution of CBT. Highlighting obstacles in therapy by sharing enriching therapeutic experiences arising through the application of empirical techniques offers an important additional learning opportunity for both novice and experienced therapists.

CBT is both a science and an art. The science is appropriately and clearly detailed in scientific journals and books and this will continue. The art of CBT is the experience and richness of knowledge that engagement in therapy offers to both client and therapist. These experiences are passed on from generation to generation, are remodelled to suit the new carrier of the torch and rarely remain the same. They are shared often as clinical anecdotes in supervision or with like-minded colleagues.

Thankfully, emerging literature detailing process factors, much of which is informed by clinical experience, is growing. The writings of Leahy (2003; Gilbert and Leahy, 2007), Safran and Segal (1990) and others highlight the growing recognition of the importance of the therapeutic relationship within CBT. No more can CBT be accused of being too mechanistic, lacking humanity or of being a kind of ‘brutalism’ (Clarke, 1999). The complexity of its application – the art of CBT – is now being recognised. Work also abounds on the development of the ‘self of the CBT therapist’. This work concerns itself with exploring how therapists can increase their self-knowledge and reflective qualities (Bennett-Levy, 2006; Bennett-Levy and Thwaites, 2007).

THE AIM OF THIS BOOK

The main aim of this text is to share information and experience with illustrated case examples, bridging the gap between theory and clinical practice. These clinical experiences are utilised to illustrate the complexities of practising CBT with clients. It goes further by suggesting how to overcome therapeutic obstacles encountered in everyday clinical practice.

This book is written for the novice therapist starting out in CBT as well as the more experienced CBT practitioner. It may also be of interest to counsellors or therapists with a level of skill and knowledge of working within a CBT framework. It is intended as a resource for practitioners, to assist in those moments of reflection on therapy experiences with clients, when feeling lost, or confused. The book offers the clinician an opportunity to keep abreast of research around the subject matter of each chapter, in a practical and clinically relevant way. While including relevant references to the literature, its primary focus is on our experiences from clinical and supervision practice. The text is intended to be rich in information of what emerges at the coal-face of clinical practice, with illustrative case vignettes. While not exhaustive, we have attempted to give an account of the experiential aspects of working through ‘stuck points’ with clients. We have reflected on how this feels for both therapist and client and suggested ways forward. Learning exercises related to each topic are also included.

BOOK OUTLINE

Each chapter offers a list of clear learning objectives. To increase accessibility for the reader, the structure of the chapters are somewhat similar. Each chapter is, however, unique and, though primarily the work of one author, every chapter is a reflection of the differing experiences of the four authors, who all contributed thoughts and ideas, especially in the editing process. The book can be read as a whole or each chapter can be utilised as a resource relating to a specific problem area. Some terms, such as patient and therapist, formulation and conceptualisation, therapeutic relationship and therapeutic alliance are used interchangeably. To minimise offence or discrimination, when referring to individuals in the third person, the gender-neutral term ‘they’ is used as much as possible but, depending on context, the gender specific he or she are also used.

The book is divided into three sections. Part 1, ‘The Process of Therapy’ (Chapters 2–5), reflects on how obstacles can present and affect the attainment of therapeutic goals impeding progress. The first important stage in the therapeutic journey is to engage the client and develop the therapeutic relationship. This, and its related obstacles, is the focus of Chapter 2. Chapter 3 elaborates on the importance of assessment, clear problem focus, model selection and formulation. This is crucial as, without a clearly identified and formulated problem, therapy is likely to stall at the first hurdle. It helpfully explores the importance of using disorder-specific models and adjusting and sequencing interventions to suit the client. Alongside the development of the therapeutic alliance, assessment, problem focus and model selection, recognising the appropriate timing of interventions is important. Chapter 4 considers the obstacles that can present as a result of poorly paced and timed interventions. Sequencing and timing problems can contribute to therapeutic impasse and failure. Timing of interventions, the developing therapeutic relationship, problem focus and conceptualisation generally revolve around the client and therapist. The client does not, however, exist as an island. Therapists and clients have lives outside the therapeutic relationship, which reciprocally influence the therapeutic process. Chapter 5 explores obstacles relating to these ‘extra-therapeutic relationships’ which can impact on therapy progress.

Part 2, ‘Psychopathology-related Obstacles’ (Chapters 6–10), though not exhaustive, considers some important clinical themes. These overlapping themes are not limited to any one specific disorder. Chapter 6 considers the issue of perfectionism in both therapist and client and how it can present obstacles to progress and goal attainment. Perfectionism can present as an issue in its own right. It can also present as an underlying complicating factor with other conditions. Working clinically with experiential intolerance is the focus of Chapter 7. This is not a topic that is routinely taught on training courses but, like perfectionism, it can create challenges in therapeutic practice. Chapter 8 explores the experience of guilt and shame and how these present in therapy. Guilt and shame can present as separate entities or be associated with a range of conditions. Their emergence can have wide-reaching effects and present frequently enough in therapy to merit discussion. Chapter 9 gives the reader a unique insight into experiences of intrusions into awareness, rumination and agitation. This chapter defines and outlines the differing types of intrusions related to different diagnoses, in such a way that might not be taught on most CBT courses. In keeping with the ethos of the book, it shares the authors’ clinical experiences as learning opportunities for the reader. Chapter 10 concludes this section by considering some of the different ways physical symptoms can create obstacles to therapeutic work and suggests ways of managing this. Throughout the text, efforts are made to consider the presenting obstacles in a thematic way, avoiding a laundry-list approach. Hypotheses based on the clinical vignettes are presented and explored, which can be referred to by the reader as a guide to decision making in treatment.

Part 3, ‘Therapeutic Context’, concerns itself with the context of therapy. Chapter 11 explores the theme of supervision and the challenges of nurturing the skills of new therapists within services. Organisations play a pivotal role in the provision of CBT, both for the client, the therapist and the developing therapeutic services. Chapter 12 explores this organisational perspective, covering two major themes: (1) the ways in which organisations can impede the development of the therapist; and (2) the ways in which they can create therapeutic obstacles in work with clients. The structure of this chapter elaborates on the development of the therapist, from qualification to experienced practitioner to service developer.

SUMMARY

In compiling this book, the authors draw from many years of experience working clinically with clients, supervision of trainees and involvement in CBT training and teaching. We attempt to lead by example in sharing our experience of ‘what really happens’ when therapist and client meet. Our hope is that this book will both inform and stimulate the interests of other clinicians in writing up their own enriching experiences of client work. This could be encouraged through single-case reports or as a reflection on ‘what works and when’-type scenarios. Such sharing of experience is a rich source of learning for all therapists. The writing of this text has been an enjoyable and therapeutically educational experience for us. We hope it will be equally stimulating and educational for the reader, providing an integrative approach to managing obstacles in therapeutic practice.

REFERENCES

Bennet-Levy, J. (2006) ‘Therapist skills: a cognitive model of their acquisition and refinement’, Behavioural and Cognitive Psychotherapy, 34: 57–78.

Bennett-Levy, J and Thwaites, R. (2007) ‘Self and self-reflection in the therapeutic relationship: a conceptual map and practical strategies for the training, supervision and self supervision of interpersonal skills’, in P. Gilbert and R.L. Leahy (eds) The Therapeutic Relationship in the Cognitive-Behavioural Psychotherapies. London: Routledge. pp. 255–81.

Clarke, L. (1999) ‘Nursing in search of a science: the rise and rise of the new nurse brutalism’, Mental Health Care, 2: 270–2.

Gilbert, P. and Leahy, R (eds) (2007) The Therapeutic Relationship in the Cognitive Behavioural Psychotherapies. London: Routledge.

Leahy R.L. (2003) Roadblocks in Cognitive Behavioural Therapy Transforming Challenges into Opportunities. New York: Guilford Press.

Safran, J.D. and Segal, Z.V. (1990) Interpersonal Processes in Cognitive Therapy. New York: Basic Books.

Part 1

THE PROCESS OF THERAPY

2

THE COLLABORATIVE THERAPEUTIC ALLIANCE

YVONNE TONE

LEARNING OBJECTIVES

After reading this chapter, the reader should:

• understand what commonly impacts on the therapeutic alliance;
• understand how to engage effectively with reticent or wary clients;
• know how to negotiate common obstacles that arise in the therapeutic relationship.

INTRODUCTION

The relationship between client and therapist (the ‘therapeutic relationship’) is central to the healing process. While historically focusing more on the maintenance cycles of disorders, cognitive therapy literature has recently been more attentive to the therapeutic relationship (e.g. Safran and Segal, 1990; Wright and Davies, 1994; Waddington, 2002; Gilbert and Leahy, 2007). The therapeutic relationship has been defined as ‘the personal qualities of the patient, personal qualities of the therapist, and the interaction between them’ (Wright and Davies, 1994: 27). The aim of this chapter is to explore common ways this complex interaction can break down under the pressure of CBT work. The focus will be primarily on short-term CBT therapy, with some reference to schema-focused therapy and its associated limited reparenting techniques. Four illustrative cases will explore common themes and obstacles associated with engagement and rupture in therapy.

KEY INGREDIENTS OF THE THERAPEUTIC RELATIONSHIP IN CBT

A good relationship between therapist and client underpins all aspects of therapeutic work. The importance of the therapeutic relationship in CBT is now informed by a very broad set of theories and concepts, including attachment.

Attachment and Alliance

The main tenet of attachment theory is that human beings have an instinct towards the nurturance of stable relationships with attachment figures. Early attachment experiences are known to influence relationships formed in later life (Bowlby, 1973) and have been incorporated into CBT theories (e.g. Beck et al., 1979; Young et al., 2003). Early in the development of psychotherapy, Freud referred to the importance of the therapeutic relationship in his reference to ‘positive transference’ (Freud, 1940). Clients may regress to an earlier stage of development during therapy. This activates schem...

Table of contents

• Cover Page
• Title
• Copyright
• Dedication
• Contents
• List of Figures
• List of Tables
• About the Authors
• Acknowledgements
• 1 Introduction
• Part 1: The Process of Therapy
• Part 2: Psychopathology-related Obstacles
• Part 3: Therapeutic Context
• Index