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Delivering CBT It is conceivable that counsellors could supply a much needed workforce capable of delivering a listening version of CBT – if they first dropped their prejudices about the model. By Frank Wills There is a big shortfall in trained therapists who can deliver effective cognitive-behavioural therapy (CBT)1. If the proposals of Lord Richard Layard, or anything like them, come to fruition, the shortfall is bound to worsen2. This raises the very legitimate question: who can fill the gap? Nurses are currently one of the largest professional groups involved in administering CBT3. However, nursing organisations have expressed concern that psychiatric nurses who are already under-strength should not be unduly plundered for this role2. This article will argue that those counsellors who would want to4 are uniquely placed to take up the challenge. But for this to happen widely, the counselling profession may need to examine some of its negative beliefs and rejudices about the model. CBT therapists who can listen I have been conducting a longitudinal study of counsellors learning CBT for the past seven years. I presented some of my early findings to a conference of the European Association for Behavioural and Cognitive Psychotherapies in Cork in 1998. During my presentation, I made the slightly tongue-in-cheek comment that counsellors sometimes 'listened too much' for CBT: meaning that the counsellor's desire to hear everything the client says sometimes makes it difficult for them to focus on specific content in the way that is required when delivering CBT. Afterwards, a trainer involved in CBT training in the NHS told me that he had the opposite problem: he couldn't get his trainees to listen at all! I remember thinking that I preferred my training problem to his. The skills training tradition has been strongly entrenched in counselling training, and results in a profession that is remarkably well able to listen5. Even before I became a CBT therapist, however, I found that many trainees wanted something more: 'OK, now I can get the client to tell me his story, but what do I do now?' My general response to this often-asked question has been, 'Well one of the things you could try is focused cognitive-behavioural work.' There is, I hear, a little bit of evidence that such work can be quite effective in helping people with common psychological problems such as anxiety and depression4. What is CBT? Cognitive behaviour therapy (CBT) can be regarded as the parent group of therapies that draw heavily on both cognitive and behavioural traditions. Beck's model of cognitive therapy is one of the most influential CBT models. Others include Ellis's rational emotive behaviour therapy (REBT), Meichenbaum's stress inoculation therapy (SIT) and Young's schema-focused therapy. In fact, the structure parallels the psychodynamic parent group, consisting of Freudian psychoanalysis, Jungian analytic therapy and object relations therapy, among others. Beck's model of cognitive therapy suggests that there are specific cognitive profiles of thoughts and beliefs that typically accompany problem areas such as depression and anxiety. Once these profiles have been formulated, therapist and client engage in a collaborative, empirical process to test out these thoughts and beliefs and their accompanying emotions and behaviours to promote enduring therapeutic change. The joys and perils of learning CBT Diana Sanders and I6–8 have written about the many, sometimes seemingly intractable ways in which people misunderstand CBT. My longitudinal research has been following trainees' reactions to the principles of CBT before, during and after training, and the ways in which these reactions may influence the way they are able to learn CBT skills9. The main principles of CBT espoused by Aaron Beck and Judith Beck10–13 are:
For my research, these principles were operationalised into an inventory, and this was administered to trainees before and after training and at follow-up. Trainees were also interviewed. Trainees' responses to these surveys were compared to their subsequent performance in CBT skills assessments. The results showed that many of the CBT trainees went into training with a strong belief in other modes of therapy, and had significant reservations about CBT principles, especially those implying direction and structure. In the case of trainees with a psychodynamic background, however, these reservations did not seem to affect the achievement of competence in CBT: in fact, psychodynamic trainees did slightly better than any other group in cognitive-behavioural skills assessments. Some of these trainees had 'conversion' experiences, and have ended up as cognitive-behavioural therapists. Others found, sometimes to their surprise, that CBT theory had more overlaps with psychodynamic theory than they had imagined14, especially in the concept of 'early maladaptive schema' used in schema-focused cognitive therapy15. On the whole, psychodynamic reservations about CBT seem to be more at the theoretical level, and may therefore have less impact on practice. In the case of trainees with a person-centred background, most were able to learn CBT without too many problems. However, a sizeable minority took significantly longer to master CBT skills than those from other training backgrounds. The difficulties seemed to be linked to these trainees' reactions to the principles of direction and structure in practice. Unlike the more theoretical objections of those trainees with psychodynamic backgrounds, their reservations seemed to impact more on their practice. In interviews conducted after training, the trainees, beginning from a person-centred background, described these struggles as follows:
Sometimes these trainees referred to the price paid in their previous training to overcome their personal tendencies towards directiveness:
Padesky16 has pointed out that therapists sometimes get restricted by their own negative 'therapist beliefs' in the same way as clients get restricted by their negative thinking. Assumptions such as 'If I structure the session, the client will feel controlled' and 'If I ask the client to do homework, they will resist me' have been quite widely reported by CBT trainees. Such negative beliefs often disregard other parts of the perceptual field: in this instance, the CBT principle of collaboration. So, what tactics can be used to overcome these restrictive tendencies? Overcoming difficulties by developing new learning heuristics Most trainees who struggled in this way eventually realised that CBT principles were not 'fundamentalist' but 'pragmatic': the aim is to help the client feel better. A fundamentalist view of CBT leads people to over-apply the model and blocks their learning. Interestingly, MacKay et al17 report a similar phenomenon among those training for interpersonal therapy. The trainees seem to get overwhelmed by a learning heuristic along the lines of 'I have to do it in the prescribed way', and this prevents them from 'playing with' the model and thus slowly working their way into it. There is frequently a crisis when previous expertise seems 'de-skilled' and new skills will not come: a zone of uncertainty like that of a trapeze artist who has let go of one swing and is waiting for the other one to smack into her hands. The result is anxiety, which can further block learning18. Happily, most trainees are able to transcend this moment of crisis by allowing themselves to rethink some of their attitudes and then to play with the new model, as illustrated in the following quotes:
As well as such task-oriented problem-solving strategies19, there was sometimes evidence of more purely conceptual changes:
Once trainees were able to 'free up' their thinking and allow these less 'catastrophic' and more 'task-oriented' approaches and thoughts to direct their learning, they often moved rapidly to CBT competence. (And of course there are interesting parallels here with the therapy process itself20.) Follow-up surveys showed that the changes were lasting ones; and while some former trainees subsequently went over fairly fully to CBT practice, most still regarded it as 'one of the things I do' (343, above), though by this time obviously in a much more organised and effective way. Opening up one's constructs is often easier in an educational environment of exploration and acceptance. So I want to end this article by suggesting that involving counsellors in delivering CBT may be enhanced by fostering a little more exploration and acceptance within our own profession. Does the counselling profession want CBT to be 'on the team'? I am an accredited BACP counsellor and Fellow, and an accredited cognitive psychotherapist with the British Association for Behavioural and Cognitive Psychotherapies (BABCP). I was present at the BACP research conference in May 2005, when a leading speaker said: 'If we are not careful, it will be CBT, not us...' Suddenly it seemed I was 'not one of us'. I thought of Mrs Thatcher's famous description of the Tory 'wets'. If this was an isolated incident, it would be of little significance. However, I have heard this kind of comment made quite frequently at BACP meetings – often when the incipient competition between models has been reactivated by the latest treatment guidelines issued by a government body. The fact is that this comment reveals a severe 'category error' in that it defines the terms 'counsellor' and 'cognitive-behavioural therapist' as mutually exclusive8 – which is not the case. Certainly a proportion of BACP members cite CBT as a prime influence on their work21. Moreover, counsellors make up one of the largest professional groups among cognitive-behavioural therapists22. I should add that I have never heard negative comments about counsellors at CBT meetings, though doubtless readers will be able to write in with examples. I believe that some of the negativity in this area arises from the fact that certain medical professionals who have always felt sceptical about counselling and therapy use CBT as a stick with which to bash counsellors and therapists. I regard such people as very unreliable allies for CBT – likely to turn on CBT therapists at a later date, just as they have done with psychoanalysts and counsellors in the past. However, I am not calling for a 'blandified' unity among therapists. Let's have some good arguments, but let's also be open to what we might learn from each other! Counsellors could supply a much-needed workforce capable of delivering the listening version of CBT. CBT cannot work without close and careful listening, and there is evidence that cognitive-behavioural therapists are just as capable of this as other psychological therapists22. We must ask, though, whether counsellors are likely to be open to taking this role on while senior figures in the profession imply that CBT is 'not one of us' or, even worse, is 'the enemy'. Perhaps the time has come for us to lie back, open our constructs and think of England! Frank Wills was born and brought up in Birkenhead and supports Tranmere
Rovers FC, facts that he believes account for his remarkable skills
in dealing with anxiety and depression. He is a cognitive therapist
living and working in Bristol. He has written, with Diana Sanders,
Cognitive therapy: an introduction (Sage, 2005) and is working
on a volume on CBT skills for the Sage 'Skills in therapy' series.
This article was first published in HCPJ, January 2006, the quarterly journal of HFCP (the Faculty of Healthcare Counsellors and Psychotherapists). For more information on this division of BACP, contact Gemma Green on 0870 443 5170 or email Julie Camfield or visit www.fhcp.org.uk References
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