The Cbt Approach To Therapy Psychology Essay
I shall discuss how CBT theories, strategies, techniques with hypno-psychotherapy could be integrated to support the conceptualization of client's issues, alleviate problems and establish longer term change. In elaborating an integrative model, I shall borrow both concepts and nomenclature from Cognitive Therapy (Beck) and REBT (Ellis) approaches interchangeably with little reference or preference to a particular individual therapy; instead focusing on their practical implementation in relation to a particular presenting problem.
The CBT approach is a directed, solution focused approach which recognizes the human striving for long term hedonism (Hough, 2002, pg. 118) over short term gratification needed for the healthy growth of the individual. Dryden (2007) states that "through rational thought individuals can stay alive and achieve happiness and freedom from pain and suffering" (P. 354). People can change, but it requires perseverance and effort which is a fundamental reason for emphasis on a directive, challenging approach.
CBT is concerned with cognitions, emotions and behaviors. Psychological disturbance is caused by holding on to rigid, illogical, irrational or biased ways of interpreting and evaluating ourselves, events, the world and others (which could be speculative rather than observed or factual). These cognitions or thoughts could be treated as "behaviors" that maybe conditioned or de-conditioned (Dryden, 2007) based on core beliefs or "schemata" (e.g. if you're not successful your worthless). These schemata could be "picked up" through negative reinforcement of traumatic and disturbing experiences e.g. childhood, or clinging to outdating feelings of anger, guilt, shame (Jones-Smith, 2012). Much of a person's own thinking, although predisposing factors such as genetics and illness are not ruled out, is a result of what people have been told by others which are accepted as absolute truth. Thus fears and anxieties maybe rooted in others but are reinforced by the individual. An individual's unhappiness arises through indoctrination, producing negative automatic (NATs), images and behaviors. These generalized distortions are (Boeree, 2002):
1. "I must be outstandingly competent, or I am worthless."
2. "Others must treat me considerately, or they are absolutely rotten."
3. "The world should always give me happiness, or I will die."
These schemas perpetuate because of self-judgment, non-acceptance and low frustration tolerance in trying to creating a safe environment. These distortions exaggerate negatively what could happen and the individual's ability to cope. For example, anxiety about anxiety, fear of being attractive because of having to "turn them down", or to fulfill a prophecy "see I failed to get a job like I thought". In addition to neurosis, anxiety and unhappiness, the CBT theoretical belief is that these misinterpretations can cause or contribute to depression, psychosomatic issues such as hypochondria and panic attacks, as well personality disorders.
CBT holds that behaviors and emotions are consistently expressed based on indoctrinated schemata e.g. avoid rejection because of worthlessness or clinging to people because I can only be happy that way. This schema can appear to fade or disappear only to be reactivated by a precipitating event e.g. the rejection of lover activates the "worthless" schema (Hough, 2002). Because cognitions happen in a conscious way the person can, through determination and action, change emotions and behaviors. However, that does not mean that behaviors cannot be changed or reduced without cognitive change - for example, it may be necessary for a binge drinker to reduce his alcohol intake to be able to focus on cognitive change.
A healthy individual has flexible thought processes, making relatively accurate interpretations of events (Dryden, 2007), and if the interpretation were based on fact to be flexible enough to accept and learn to cope with the situation e.g. through learning.
The key strategy for change in CBT is to make the client aware of his irrational beliefs and modify them through experiential learning. It is a common misconception that CBT sees no value in tracing illogical source of problem in past, but it is the way that it perpetuates and compounds the original problem in the here and now should be the focus of therapy (Hough, 2007, pg. 115). In addition, it is action as well as insight which are necessary to de-condition schemas and irrational thinking; it is these obstacles to happiness that need to be removed to enable the individual to be fulfilled.
The basis for utilizing both CBT and Hypnosis is based on good evidence of efficacy of both treatments (Martin, 2007, Wikipedia, 2012, NICE, 2008) based on the theory that when you focus on something, you amplify it in your awareness (Yapko, 2008 cited in Martin, 2007). However, Ellis himself believed hypnosis not to be an elegant solution (Martin, 2007) as he felt that conscious effort would be needed for longer lasting philosophical change, but based on successive approximations (in and outside trance) hypnosis can be utilized to allow clients to arrive at conscious solutions, rather than Ellis's view of bypassing consciousness which is not an accepted theory of hypnosis (Yapko, 2008 cited in Martin, 2007). From my initial work with clients (case study) I believe hypnotherapy works seamlessly with CBT, for example in the approach of modifying irrational phobic beliefs "I will die" cognitive beliefs into productive suggestions and action orientation (e.g. desensitization) within trance.
I shall use the following psychotherapeutic framework (modified: Heap & Aravind, 2009) for the basis of discussion on CBT techniques that can be utilized in hypno-psychotherapy:
Client Assessment. To assess the client problem and whether his presenting problem could be suited towards a CBT approach.
Develop working model. The basic assumption of client's problem that directs therapy.
Depth understanding. Apply strategies and techniques that allow deeper understand (dysfunctional thinking or behaviors)
Therapy. Once the client understands his need for change to apply therapeutic techniques that reinforce and encourage longer lasting change
Action Orientation. Setting of homework tasks that allow for deeper understanding, actualize changes and reinforce cognitive change
These are not linear stages of therapy but are likely to be iterative and non-sequential in nature as the depth of relationship and understanding of client's problem matures. E.g. the working model may initially be the therapists working model but could then become the clients working model.
The basis for a CBT approach is the willingness of the client to be goal focused, able to present his problems specifically, and accepts the rationale behind the CBT approach that thoughts are behind certain presenting problem(s) (Dryden, 2007). If the client presents resistance, disagrees with its basis or simply is in a "confused" state it is unlikely to be the appropriate approach to utilize. However, a skilled practitioner, combined with trance or talk therapy, based on indirect metaphor and story could be used to decrease resistance. For example, a benign induction, deepening, sensory and ideo-motor suggestions e.g. arm levitation, could be used at the beginning of a session to help the client get used to the process of listening and reduce his resistance as well as allowing the client to be more "open" about his issues and beliefs during talk therapy (Heap and Aravind, 2009). In addition, if a CBT approach is to be adopted the client will need to commit to tasking outside of therapy. Another test for determining whether to use a CBT approach is for the therapist to use Safran and Segal's short term therapy scale (Dryden, 2007). It has also been suggested that problem solvers and analytical or goal motivated individuals may benefit more from CBT. In addition, according to Dryden (pg. 372), he has not been successful with CBT where goals are based on changing others e.g. to love them and the client has stuck to that, where bond with the therapist becomes a goal, and no diligence in performing the exercises.
An initial ABC assessment by the therapist and subsequently by the client could be used. As an example (Figure 1), the "helpful" column can guide the therapist and/or client to analyze and target cognitive or behavioral changes during therapy:
After submitting his first essay to his college for assessment, the student receives a B grade and a comment from the assessor that "he believes I used the course notes for certain aspects of essay but did not reference them"
Beliefs / Thoughts
I put hard work into the essay and did not use the notes at all. It sounds as if I am being called a "cheat", "liar" and worst of all "incompetent". Don't they know who I am! I certainly don't need help from the course notes, as I am far more advanced than most people including the instructors and assessors! I can make my own insights without reference to their notes!! How dare they insinuate! They just don't like me - is it the color of my skin?
I put hard work into the essay but it was the first one and to get a B grade isn't bad at all. I'll take the feedback and learn to do better next time. I am a little disappointed by the comment as I know it is not true that I used the course notes, but it does not mean I am being accused of cheating but perhaps forgetting to reference the notes. I'll let them know that I did not use the notes so they assessor can learn something about me and perhaps improve his feedback wording for next time. That is all I can do, it's up to people if they want to believe me or not and anyway it won't affect my grade or ability to pass the course! So no harm done.
Anger, resentment, shame of being accused when totally innocent, down mood. These emotional feeling lasts for days.
Disappointment passes quickly. Energized and content.
Heart beating faster, obsessive cognitive thinking, raised blood pressure, over heated forehead.
Expresses anger over the comment in an email
Avoids the assessor who is also the instructor during next weekend's training.
Participates with contempt for the instructor and takes every opportunity to disagree with the instructor.
Decides to raise the feedback at the next weekend with the assessor.
The assessor understands the student's disappointment with the comment but elaborates that it was just a piece of feedback based on a "hunch" to ensure student covers all references.
He understands the disappointment and makes sure future feedback is not ambiguous and reassures the student that it would not make a difference to the grade received.
His behavior "does not work" and so he becomes withdrawn and then lacks motivation to continue or participate at all.
The lack of participation makes the instructor believe that this is a poor student and does not want feedback or help.
Student drops out of training and goes back to a job he does not enjoy!
The student and instructor relationship is enhanced and both student and instructor learn something about each other. The student goes on to become a successful teacher.
Table - Example ABC model (D-Disputing and E - effective philosophical change)
Develop a working model
The therapist can work in producing a working model or assumption, based on the clients presenting problem(s) based on client assessment (Figure 1). In this case, the irrational beliefs can be condensed into a set of schemas or rigid absolute truths that the client may be holding on to. For the example provided, these IBs and could be theorized as:
IB1 - People don't like me; clue: reference to color of skin
IB2 - People should always believe me; clue: believe I cheated
IB 3 - If they don't believe me, it is terrible and cannot be tolerated ; clue: indignation and intolerance
IB 4 - If I cannot be seen to be competent it is terrible; clue: I am better than everyone else
IB5 - I need to be better than others otherwise I am worthless; clue: the overall reaction and need to be correct and the energy expended versus the actual issue
In this case, the therapist could develop a working model (or assumption) that because the client believes people don't like or believe him, he sees himself as worthless or in an inversely to be liked and believed I need to be seen as masterful and competent. The emotional affect of this cognitive structure is a pattern of anxiety, anger, hurt feelings and a poor self concept that perpetuates due to these hardcoded "schema" which does not allow the client space to be able to rationalize his thoughts and their consequences.
Therefore a "treatment" plan could focus cognitive restructuring techniques based on self acceptance, fallibility and realistic view of people in the world. Behaviorally techniques that promote reflection rather than anger and one of curiosity rather than confrontation could be deemed most appropriate based on this working model. This working model could eventually become the model the client adapts to reflect on activating events which he can be responsible for managing.
Depth of understanding
Once the therapist has established a working model, he can target appropriate techniques and procedures that will enable the client to obtain self-determined insight. Needless to say the therapist himself should not rigidly cling to his working model and be ready to adjust it based on the client's beliefs. Ellis lists the principal methods of depth understanding as, a) debating, b) persuasion, c) suggestion, and, d) positive thinking. (Martin, 2007)
In CBT, Socratic questioning and debating looks for evidence, for or against beliefs. For example "is there evidence that anyone called you a liar?" or "what made you think you were being called a liar?" What if or the worst that would have happened if they thought you had cheated? How important would that have been in practice? What would happen if you gave up the belief that you were not liked? What would the benefits be of giving up a belief? Do you like everyone?
In the example provided where the client wished to be masterful, the therapist could self disclose errors to show his fallibility and yet accepts and does not judge himself (humor could be an option here). This indirect method of shedding light on targeted IBs allows for the therapist to act as an emotional re-educator in the CBT sense.
This type of re-education and debating can also be targeted at the behavioral and emotional level particularly where the client is not ready to fully understand cognitive based issues. So for example, it may be easier for the client to see that getting angry does not always produce the desired result and you may end up taking actions that are regrettable. In this case the client could be encouraged to look at alternative options and their pros and cons (Boeree, 2002). In cases where client is distressed giving the client space to remain calm, logical and reflective may be the best starting point for therapy e.g. where client is prone to lash out in anger.
Hypnotherapy offers a range of specific interventions that could be utilized with Cognitive-Behavioral Therapy, some 38 modalities are described in by Donaldson, (2007), only some of which I have described. Based on the law of successive approximation, hypnosis techniques can be harmonized with CBT. At first focusing on rapport and relaxation, establish relevant childhood events that are still impacting the here and now, regression based on a "sample" problematic events to be reflected upon as part of the debating process, enhancing desired behavioral change e.g. cues, indirect targeting of core irrational beliefs (e.g. story or metaphor technique), ego strengthening and once IBs have been accepted as being problematic through direct suggestion and homework activities (including self hypnosis).
CBT believes that schemas of automatic thoughts could be picked up during childhood. Through trance and its qualities of attention, absorption and imagination, triggers or suppressed childhood material could be identified by the client to reveal insights (Heap and Aravind, 2009). Through reconstruction of painful events with disassociation (detachment from emotion) and Ideomotor signaling (IMR), the client can determine whether there are any important memories relating to clients problems that could reveal suppressed schema e.g. childhood rejection, inferiority or bullying which is causing problems in the here and now - in this case the need for mastery. This reconstruction method can also be used to explore past scenarios, faulty behavior, alternative options and their positive or negative consequences. This is not to say that the client may not be able to recall these memories without trance but make him aware of their continued effect (Heap and Aravind, 2008, p236).
Hypnosis can support behavior modification once cues and salient triggers for negative behaviors have been established. For example, each time you feel yourself get angry you will say to your unconscious mind, "Thanks for trying to look after me, and you will say "relax I'm in control" which will remind you of a scene of playing happily with your new born child". In this way behavior therapy helps you weaken the connections between troublesome situations and habitual reactions to them, so you can think more clearly, and make better decisions.
Another indirect way, using hypnosis or talk therapy, is to develop metaphors based on targeted IBs. For example, in the case of this client needing to be liked to feel worthwhile, the story of the father and son who travelled with a donkey (Heap and Aravind, 2008) and did not want to disagree with anyone's advice and ended up tired and thirsty, carrying their donkey home. Hopefully, the client would gain insight that "isn't it tiring trying to be pleasing to everyone, which is hindering my journey and stopping me achieving my goals?" Other metaphors can focused on fallibility, such as the use of the journey method where we learn at each point of the map; reconstruct a new map based on our experiences.
The therapist could create a repertoire of metaphors and stories that discretely target particular types of IB based on each of the general IBs developed by Ellis and Beck. E.g. A generalization schema could be contrasted to a school playground where children make and break friendships based upon hearsay as they don't have the skills to communicate or look for the facts, but as adults we learn to look for facts and create healthy relationships that can be difficult at times. This approach, has the added advantage of allowing the client to focus on his emotions (law of dominant effect) to exact change rather than over reliance on IB analysis in CBT (Heap and Aravind, 2009)
Longer term change therapy
Once IBs have begun to be accepted and the working model refined, therapy can focus on reinforcing these insights to produce longer lasting cognitive and action oriented change.
The incorporation of "corrective" cognitive behavioral suggestions becomes central to longer lasting change (based for example on the law of concentrated attention). For example, if the client accepts that people don't always have to like me a direct suggestion (Martin, 2007) could be given in trance or talk therapy as "it would be preferable to be liked but I can't always be liked by everyone, and plenty of people do, it wouldn't be dreadful but I am still worthy". This is very much aligned to a CBT approach where right self-talk is necessary for change, substituting IBs with a more balanced way of thinking.
Where the client is fearful or anxious of a previous or future situation, graded in vivo exposure or systematic desensitization can be either in reality or imagination. In this example presented, the client may be fearful of confrontation, so could be taught methods of deep relaxation through trance or progressive muscular relaxation and establish a hierarchy of fears e.g. being able to be in the presence of someone they dislike to discussing the issue with them. This hierarchy of fears could be worked on between sessions as homework.
Alternatively, or prior to in vivo exposure, hypnosis with age progression or rational emotive imagery techniques could be incorporated (Hough, 2002). For example, anxiety to confront an issue rather than avoid it, the client could be imagine disclosing feelings or situations in a calm way and imagining the counter conversation he would have to arrive at a conclusion (in this case with his instructor). The client would be encouraged to imagine the situation, using his new found rational beliefs and feeling and noticing the way it feels and the possible outcomes (including ones where the conclusion is not satisfactory).
Ego strengthening can now be employed actively as part of therapy where the client is making progress as a way of helping people to enhance their self-confidence and self-worth (Heap and Aravind, 2009) i.e. affirming physical strength, equanimity and mental strength. In this example, the client needs "strength" to accept himself regardless of gaining everyone else's approval.
Humor could be used to highlight the ludicrousness of certain beliefs (Neenan & Dryden, 2006), to reinforce progress. For example, "imagine the exhaustion of keeping up with so many friends".
Homework between sessions could be a useful tool, client willing, to enable reflection on possible IBs and desired outcomes. The client is encouraged to "intercept" negative automatic thoughts (NATs) and images (Hough, 2002) and thoughts that come to mind and log these (e.g. using the ABC worksheets) and then "discuss" these situations "with himself" or during sessions to reflect what he would do differently and to analyze the way in which his actions or thinking were faulty. Ellis stated that the RB (rational beliefs) could now be incorporated into "rules of thumb" so client could accept them consciously (Martin, 2007) e.g. mental repetition, note to self every day or through self-hypnosis.
Home work could include rehearsal (rational emotive imagery) during self-hypnosis or in graded Vivo desensitization for difficult scenarios. Grades could include, for example, just being in the presence of someone they don't particularly like, to smiling and saying hello, asking them a question, up to discussing a concern.
Homework allows for the validity of fears or IBs to be tested in reality (NCHP, 2011). For example, making note of people that appear to be "perfect" and whether they admit imperfections about themselves or whether people would stop liking you if you admitted to not knowing something, showing vulnerability or making a mistake. Another ploy for clients that appear not to get pleasure out of activities to rate pleasure ratings (Neenan & Dryden, 2006) or if "no one cares" to list details of phone calls or interactions that looked like someone was helpful.
A CBT approach also encourages the client to undertake new activities that channel positively maladaptive thoughts or behaviors (Jones-Smith, 2012) e.g. channeling anger to martial arts or lack of attachment to community work, particularly where these activities require social interaction. This action oriented approach also acts as a positive ploy to reduce "think time" i.e. the focus of overloaded and obsessional negative thinking.
The client could also be asked to keep a diary which enables him to reflect on scenarios, describe improvements and areas he would like to explore in session. For example, he could describe how he was feeling following reducing his drinking habits or the reoccurrence of anger and what he thought triggered it and whether it was a beneficial reaction.
As I have discussed a CBT approach offers many practical strategies and techniques that can be integrated within hypno-psychotherapy. However, a creative therapist must not fall into the trap of applying a "process" to enable the client to change, and in particular assess whether the client has actually achieved a longer lasting "philosophical" (Ellis) change necessary in a CBT approach.
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