Recently, I undertook and graduated with a Diploma in CBT. I remember, on discussing with a colleague at work that I was considering the course, that she asked me, surprised, “but why would you want to do that Tania, you are so person centred”. “Exactly!”, I replied.
During my initial counselling training in 2002, we were taught how to support clients integratively. That is, to draw from a variety of models and theories to support the client in the best way possible given their circumstances and preference. I found myself naturally drawn to a person centred model. One which derives from Carl Rogers, a man who believed in the ability of every human being to self-actualise, given the right conditions. These condition could be created in a therapeutic environment and would be enough to support a client to find their own way of managing their situation or circumstances.
Now I continue, even after I have been through the CBT sausage machine (!) to believe strongly in Carl Rogers work and the person centred approach. However my curiosity, and my need to find out if there was anything else I could be doing with my clients that might help them, felt like a responsibility. Like mindfulness, CBT is still a buzzword in counselling and therapy, and I am someone who likes to find out for myself what the buzz is all about. I owe it to my clients, my workplace, and my self-development as a person and practitioner to move with developments in the field.
In the bereavement world it was not so long ago, that the person centred approach, and supportive listening stance was being advocated as the main source of support for bereaved clients that required counselling. And let’s not devalue this much respected model, the core conditions are incredibly powerful and healing, and I have been privileged to work with and know some genuinely brilliant and effective person centred practitioners. To a large extent, it makes up the majority of bereavement support required in usual grief circumstances, and forms the basis of training for listening services. Yet I have found, that there are occasions, particularly when working with complex grief that CBT skills really do come into their own. And I did not expect this.
CBT was derived by combining both cognitive and behavioural based therapies over a number of years with a series of significant contributions by several esteemed therapists, most notably perhaps Aaron Beck and Albert Ellis. By identifying how our thoughts and feelings affect our behaviour we can proactively work on understanding and reviewing our responses to previously learned automatic thoughts and behaviours that may not be serving us well.
I truly began my course with a large bout of scepticism. By month 3, I was still frowning and had no idea how I would congruently integrate CBT in its purist form into my bereavement practise. How could I introduce the GAD7 and PHQ, Core10 and formulation into a session of grief? What collaborative treatment plan could there possibly be for someone who does not see the value in life after the death of the person that died in their life? However something just clicked, when working with clients and trusting the process, it all fell into place. Consider a complex client* whose bottom had fallen out of his world. With no direction, focus or energy, he is severely depressed and lost. In the past, I would have trusted the therapeutic process. That by providing him with the person centred core conditions, he would find his way through. And I would hold onto this belief until it happened. Inevitably it would. New distractions would be utilised, a different direction tried, or a gentle reprieve from the intensity of grief would occur naturally over time whilst sessions remained completely client led.
In college we learned how to deliver pure CBT. That is to identify, plan and deliver a treatment programme for a variety of disorders. This is no mean feat. Often these disorders are a result of a lifetime’s deep set core beliefs and behavioural systems. CBT can sometimes, be seen both as a last resort, or as the ultimate treatment for particular conditions. CBT practitioners need to believe in the CBT process and in their client’s ability to do the work, because it is a very proactive therapy. The client must be prepared to work through certain tasks. For those bereavement professionals amongst us, this ties in well to William Wordens tasks of grief, Stroebe and Schuts restoration orientation, or Machins Ranges of response to loss models of grief, the concept that grief can be worked through in a proactive way.
Clients sometimes benefit from the setting of particular tasks of grief, and some practical adjustments do need to be made. Some social aspects may need to be addressed, or relationships negotiated. For some, constant rumination and over processing of what has occurred in bereavement becomes upsetting, frustrating, and debilitating.
This is not to say that the telling of a story, situation, or associated thoughts feelings and fears should not be shared and repeated again. On the contrary, it is known that this can be helpful and necessary. Robert Neimeyer in his writing and theories on meaning making makes a good case for this. In CBT, such time can actually be written into the work plan so that time is made for processing and the narrative. Tools such as a grief journal help with this part of the work. Sometimes, in my experience, especially in the case of a sudden or traumatic death, the story needs to be retold many times in order for the brain to process what has happened. However there are aspects that more direct interventions can help with.
Consider again the grief gentleman client above, feeling that he was now without purpose and role. The use of the powerful downward arrow technique, might lead to him discovering that he had relied on his role as a carer and before that provider to give him a sense of worth, stemming right back to being a youngest child of an alcoholic, with a core belief of ‘i am not worthy’ or ‘I am unlovable’. This powerful realisation, may lead him to identify repeating patterns that are no longer helping him, and decide to work on establishing a robust sense of self and direction through short and long term achievable goal setting.
Activity diaries would most likely capture a distinct lack of activity and social interaction, which we might build gradually through the setting of homework tasks into his week. Formulations or ‘hot cross buns’ separate thoughts feelings behaviours and beliefs to help him identify and understand patterns and break cycles. Mindfulness podcasts may help with his anxiety attacks in the night, retraining his patterns of sleep and restful breathing exercises for when he woke early. A whole individualised treatment plan would designed for the remaining sessions planned together.
Whilst CBT would not be a magic cure for his bereavement, it would give him some tools to help him work through certain aspects which in turn would increase his resilience in order to deal with the challenges the death of his wife had presented. Together, we would through a series of sessions with a mutually agreed agenda where we would hopefully see his PHQ and Core scores drop steadily, and if not, we would review our work.
Alex recently told me that she has sometimes referred to CBT in the past as Codswallop and Bollocks Therapy (!), believing in her experience, that many do not require a structured therapeutic approach to some very normal responses and situations encountered at end of life and in bereavement- and she has a point. We all have a responsibility not to medicalise a natural process, and certainly not everyone needs such an intervention. However for those very stuck, there are options, and there is always hope. I have learned so much. I am particualry interested in so called’ third wave CBT’, a new wave incorporating mindfulness techniques and approaches such as Acceptance and Commitment Therapy.
There is no fast track through the grief process, no quick fix in 8 or 10 sessions. However CBT can support and empower people, increasing their resilience to manage their unique situation with a treatment plan especially tailored to their world. It is a specialist approach, which requires the right training and supervision and for interested practitioners, I would suggest researching courses carefully, and meeting with the tutors before committing to the process. For some, the Improving Access to Psychological Therapies (IAPT) model adopted by Any Qualified Providers and commissioners of counselling services will be a first taster of delivering or receiving shorter term therapy, this short term counselling intervention is quite different from CBT in its purist sense, with the IAPT model having moved away from many core CBT principles, for example restricting the number of sessions even further below the CBT recommended level for very complex disorders. I understand that the exceptionally skilled Christine Padesky is working with the NHS to review its IAPT programme which should be reassuring to us all. With services and commissioners increasingly looking towards short term models with evidence of proven effectiveness, and CBT and IAPT practitioners trained to use monitoring outcome tools in every session, like it or not, shorter term models are here to stay, and as practitioners we have a choice whether to engage and incorporate them into our practise. For me, the journey has been totally worth it.
*For the purpose of this article, this client is completely fictional and provides representation of a grief client.
*I am eternally grateful to all that have supported me through and been a part of my CBT journey thank you all.
*Views are my own and not of any employer.
The British Association Cognitive Behavioural Psychotherapies (BABCP) provides useful information on membership categories, information about accredited training, and courses or finding a therapist here:
More about what CBT is and how it works can be found here:
Get Self Help website has an amazing array of incredibly useful worksheets and resources:
As does Psychology tools