Cognitive behavioral therapy

What does clients find most helpful about therapy?

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This is a reblog from Damon Ashworth Psychology! A brilliant post that I hope will be helpful and interesting.

Therapist-and-Patient

When clients first begin their therapy journey, they often ask to be taught specific skills that are going to help them achieve their specific goals.

They believe that if they can be taught these skills, they will be able to overcome their difficulties, or the problems that led to them entering therapy, and they will have no subsequent difficulties or need for additional therapy going forward.

Cognitive Behavioural Therapy (CBT) is a short-term treatment that clients can easily understand. It is based on the premise that all difficulties arise from unhelpful cognitions (beliefs, expectations, assumptions, rules and thoughts) and unhelpful behaviours. CBT aims to help clients see that their cognitions and behaviours are unhelpful, and tries to teach them skills that can help them to replace these unhelpful cognitions and behaviours with more helpful ones. If this is achieved, the assumption is that clients will change and therefore improve.

I do believe that if a client is able to have more helpful cognitions and behaviours then they will have significantly improved psychological health and overall well-being. I’m just not sure if I agree that the process that is required to get to this outcome is the same as what many CBT clinicians would believe. In fact, focus on distorted cognitions has actually been shown to have a negative correlation with overall outcomes in cognitive therapy for depression studies (Castonguay, Goldfield, Wiser, Raue, & Hayes, 1996).

What actually leads to improvements across treatment?

My previous article “What Leads to Optimal Outcomes in Therapy?” answers this question in detail and shows that the outcome is dependent upon (Hubble & Miller, 2004):

  • The life circumstances of the client, their personal resources and readiness to change (40% of overall outcome variance)
  • The therapeutic relationship (30% of overall outcome variance)
  • The expectations about the treatment and therapy (15% of overall outcome variance)
  • The specific model of treatment (15% of overall outcome variance)

For cognitive therapy for depression, both therapeutic alliance and the emotional involvement of the patient predicted the reductions in symptom severity across the treatment (Castonguay et al., 1996). Many therapists are now aware of these findings, but clients are generally not.

What do clients view to be the most valuable elements of therapy once they have improved?

By the end of treatment, especially if it is a successful outcome, clients tend to have a much different outlook on what they think are the most valuable aspects of therapy when compared to what they were looking for at the beginning of their treatment.

In Irvin Yalom’s excellent and informative book ‘The Theory and Practice of Group Psychotherapy’, he goes into detail about a study that he conducted with his colleagues that examined the most helpful therapeutic factors, as identified by 20 successful long-term group therapy clients. They gave each client 60 cards, which consisted of five items across each of the 12 categories of therapeutic factors, and asked them to sort them in terms of how helpful these items were across their treatment.

The 12 categories, from least helpful to most helpful were:

12. Identification: trying to be like others

11. Guidance: being given advice or suggestions about what to do

10. Family reenactment: developing a greater understanding of earlier family experiences

9. Altruism: seeing the benefits of helping others

8. Installation of hope: knowing that others with similar problems have improved

7. Universality: realising that others have similar experiences and problems

6. Existential factors: recognizing that pain, isolation, injustice and death are part of life

5. Interpersonal output: learning about how to relate to and get along with others

4. Self-understanding: learning more about thoughts, feelings, the self, and their origins

3. Cohesiveness: being understood, accepted and connected with a sense of belonging

2. Catharsis: expressing feelings and getting things out in the open

1. Interpersonal input: learning more about our impression and impact on others

The clients were unaware of the different categories, and simply rated each of the 60 individual items in relation to how helpful it had been to them.

What becomes apparent when looking at these categories is that giving advice or suggestions about what to do is often not found to be a very helpful element of the therapy process, even though this is exactly what most of the clients are initially looking for. What is far more important is the client developing a deeper knowledge of themselves, their internal world, and how they relate to and are perceived by others in interpersonal situations.

 

The top 10 items that the clients rated as most helpful were (Yalom & Leszcz, 2005):

10. Feeling more trustful of groups and of other people.

 

9. Seeing that others could reveal embarrassing things and take other risks and benefit from it helped me to do the same.

 

8. Learning how I come across to others.

 

7. Learning that I must take ultimate responsibility for the way I live my life no matter how much guidance and support I get from others.

 

6. Expressing negative and/or positive feelings toward another member.

 

5. The group’s teaching me about the type of impression I make on others.

 

4. Learning how to express my feelings.

 

3. Other members honestly telling me what they think of me.

 

2. Being able to say what is bothering me instead of holding it in.

 

1. Discovering and accepting previously unknown or unacceptable parts of myself.

Each of the 20 clients that made up these survey results had been in therapy for an average of 16 months, and were either about to finish their treatment or had recently done so. Obviously these items were in relation to group therapy, so the most important factors for change across treatment in individual therapy may be different. However, even with individual therapy, Yalom believes that in the end, it is the relationship that heals.

For more information, feel free to check out Chapter 4 in ‘The Theory and Practice of Group Psychotherapy’ by Irvin Yalom and Molyn Leszcz (2005), or any of the other studies out there that look into the outcomes or therapeutic factors involved in change across psychological treatment.

If you have ever wanted to discover and learn more about yourself, accept yourself more, express yourself better, take greater responsibility for your life, challenge yourself and develop more trust in others, a longer-term psychological therapy may be just what you need!

 

Dr Damon Ashworth

Clinical Psychologist

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Is the glass half empty?

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Is Your Glass Half Empty?

English: CBT framework

Be honest with yourself…are you one of those “glass half empty” types? Well if you are, you certainly aren’t alone. Many people tend to think in negative ways rather than to have positive thoughts.

What is even worse, our brains feed on repeated negative thoughts and can start locking in negative “neuron firing patterns.” In other words, our minds become more proficient at negative thinking habits.

So what, if anything, can be done about this? Well below are some excellent suggestions for you to consider. You can always go to the website direct for detailed information.

> Know Your Current Thinking Pattern:

In order to begin the change from negative to positive thinking habits, you need to learn how you currently process information. Here is a link which should help you identify the type or kind of negative thinker you are. Read and take notes as this is a crucial step in the change process. The link is: “chakrahealing.com.”   

> Isolate And Change Negative Thoughts:

The process by which you can begin to change negative thoughts into positive ones is called “cognitive-behavioral therapy,” or (CBT). The simple explanation of how this works is this. You stop whenever you have a negative thought, examine it for accuracy, and if it is baseless, you will learn to replace it with a positive thought. Again here is a link which gives much more information on (CBT): “socialanxietydisorder.about.com/od/treatment”

> Learning To Cope With Criticism:

A large part of the CBT process involves learning to deal with the judgment and criticism of those around you. Some suggest this is effectively done in therapy sessions. However, it is possible for some to learn how to restructure their thinking with self-study. You will need to build up your personal assertiveness skills. Once again, here is a website which can help with this: “socialanxietydisorder.about.com.” Look for “Assertive Communication” under the “Coping” section.

> Practicing “Mindfulness:”

Mindfulness is a technique which is born from meditation exercises. Here you learn to separate yourself from your thoughts and emotions, and make them “outside observers.” You will then learn to see thoughts as “objects” floating by you one after the other. You can stop the show by choosing to examine one, or let it pass you by. As the article says, the object of mindfulness is to gain control of emotional situations while allowing the thinking part of the brain to take control. Mastery of this practice is a step-by-step process and will take time.

> Thought Diaries:

Thought diaries are helpful in training you to identify negative thinking styles and how thoughts, not situations, can unwanted negative emotional reactions. Most behavioral modification programs will involve a diary or journal of recorded situational experiences and the thoughts which you had to them each day.

> How To Set Up A Thought Diary:

Here is an example of how to plan and maintain a thought diary. All you have to do is to record the negative thought you had each day, and the emotional and physical reactions you had to it. As an example: The thought may have been ”anxiety.” The emotional response was “fear or discomfort.” And the physical response was “racing heartbeat, sweating, etc.” It is also very helpful to record where you were when you had these things happen. Again this is a day-by-day exercise and can take time to see results, but stick with it no matter what!

REFERENCE: “socialanxietydisorder.about.com,” by Arlin Cuncic, January 31, 2012.