Anyone for CBT...? (Part 3)

“CBT is the New Coca-Cola: This house believes that cognitive behavioural therapy is superficially appealing but over marketed and has few beneficial ingredients.”*

I have a colleague of whom I am extremely fond. He is warm, compassionate and highly intelligent. He is also a good therapist. He is good at making relationships with his clients because he is essentially likeable and trustworthy and cares a great deal about their situations. He does not pay heed to any relational dynamic in sessions, however, even if the dynamic is getting in the way of dealing with the content. He is confident in his therapeutic skills, but also aware of the limitations of his particular modality and is not afraid to refer someone on if he feels unable to help them. He will usually refer on either to myself (a humanistic psychotherapist) or to one of our person-centred colleagues. He is a clinical psychologist and a CBT practitioner.

We often discuss the differences in our methodology, theory and philosophical assumptions. Sometimes we agree. Sometimes we agree to differ. But we maintain a mutual respect both for each other and for our different disciplines and we share an understanding that we both have significant contributions to make to the clinic in which we work.

My colleague is very experienced in his field, having worked as a psychologist for the best part of 20 years. He believes that there are people for whom CBT just doesn’t work. These include:

• Those who have experienced early trauma or abuse resulting in a fractured or disordered sense of self.
• Those who have experienced early significant relational deficits, resulting in attachment difficulties.
• Those who present with rigid defensive processes that they are ‘unwilling’ to give up (often referred to as ‘de-motivated clients’.)
• Those who engage with the world primarily on a feeling and/or behavioural level, and find it harder to engage their thinking.
• Those with a schizoid - or ‘shut down’ - process who have difficulty articulating their interior world.

The clinic in which I work has some very skilled and experienced practitioners, all trained in different modalities. We understand that we share many commonalities and that our ways of working are much more similar than they are different. We share a common assumption that the therapeutic relationship is of paramount importance. There is little dogma regarding modality, although there is occasionally some friendly banter. Irvine Yalom - an existential psychotherapist - said that we find a different therapy for every client. I like to think that I and my colleagues work in this way. That we use a wide range of skills, knowledge and processes to genuinely meet people in a place where they can start to contemplate change.

I think the key to our success is that we are skilled at assessing different psychological presentations and processes and ensuring that the individual is referred to a practitioner who is skilled at working with that particular process. For example, I am not so hot at working with the schizoid process. This is nothing to do with my training, knowledge or experience but is part of my own psyche. I am damn good at working with an ‘anti-social’, narcissistic or paranoid presentation however, which is lucky because most of my colleagues would see that as a definite hospital pass and are happy for me to take the referral. And so, hopefully, clients get an individual response to their individual needs.

My CBT colleague is as critical of the government’s current proposals as I am. (Which, in case you missed it, is to significantly increase NHS provision of psychological therapies, providing that the therapy is CBT. See previous post if you can be bothered.)

The government's proposals mean that a therapy will be prescribed before anyone has done an assessment of the individual's needs. I love Stray's analogy in the comments thread of my previous post: we have found that a plaster cast works well if you have a broken arm. You do not have a broken arm? Well, I'm sorry, then we can't help you. An ideal world would see NHS provision working along similar principles to the clinic in which I work, where rigorous assessment is the cornerstone of good practice and human beings run the system rather than the system running us. I can live in hope, I suppose.

*Debate held at the Institute of Psychiatry in 2005. I just fancied being provocative.