One time I was carrying out some work for a large organisation that wanted to train a lot of people to do some assessment work. It annoyed me for some reason, and I’ve finally hit on the problem (OK, several years too late, but never mind!). The problem was that instead of teaching principles, I was asked to train on process and procedure. Now I don’t know whether this is a ‘me’ thing, or a more general thing, but I find that if someone tells me to do something following a certain structure or format, I NEED to know the underlying framework so it makes sense to me.
What does it give me? It gives me flexibility – and this is why I haven’t yet posted on specific questions to use when learning skills in carrying out cognitive behavioural therapy. Today’s post is an endeavour to look beyond the specific questions to ask and into the underlying direction and rationale for the questions. I think that for occupational therapists, physiotherapists, nurses, social workers – anyone who uses CBT alongside other therapies or activities – it’s necessary to be very flexible, because we can’t rely on the pre-determined structure of a CBT session to ‘programme’ the level we might work at.
For example, I was working with a woman yesterday who was undergoing a trial implantation procedure. She had been through many pain management programmes and seen many different therapists over the 10 or more years she had experienced her neuropathic leg pain. I was talking with her about what would happen when she returned home with her new device implanted, and working to draw up a daily plan of activities. As I started to sketch out the most important activities in her day and put in a rest period, I noticed a change in her affect.
At this point I asked her ‘What was going through your mind just then?’
She replied that she would never have stopped doing her household tasks ‘just to take a break’.
In many cognitive therapy sessions, this would have been the cue to work with her automatic thoughts and help her challenge her underlying rule that ‘you should always finish a job you start’. The typical pattern of enquiry would be to ask what that thought meant about:
- herself as a person
- other people in general
- what it would be like to violate that rule
- what it meant about her pain
In this case, given the timeframe I had and the purpose of the session, I decided to follow a behavioural tack. After confirming that she was ready to try taking short breaks, and reflecting to her that I wondered if she might find it difficult at first to stop in the middle of a task, I started working with her to identify ways she could remind herself to take a break – and reward herself.
Now if we were following a ‘trained monkey’ approach, we may not have siezed this opportunity – we may have either decided it wasn’t an important focus for the session, or tried to work through the questions that are usually used to help someone challenge their thinking.
What am I trying to say here?
- That it’s important to think beyond a formula or recipe
- That attending to the overall purpose of the session is important, but to take opportunities as they arise
- That choosing from a range of options, and being respectful of the individual’s values, can mean the door remains open
- That knowing the underlying principles of cognitive behavioural therapy opens up options that relying on a process can’t offer
What are some of the principles?
- The basic foundation of CBT involves understanding the cognitive elements as well as the behavioural elements
- ‘Homework’ is not the only way to assist with behaviour change!
- Behaviours respond to behavioural reinforcement that includes rewards, recording results, and social modelling – thoughts and beliefs, while important, don’t always have to change first. They may in fact change as a result of discovering that new behaviours are working.
- Having in mind the formulation (explanatory model) that is being developed and/or confirmed helps guide your interventions.
- Core beliefs may be the reason someone finds it hard to use a new strategy. Unhelpful core beliefs, especially those that are applied rigidly, may be resistant to change.
- Past events don’t need to be revisited except insofar as they help you and the person gain insight into their current beliefs and behaviour.
What do I mean by process?
This is what I also call ‘cookie cutter’ therapy. This is therapy that relies on a series of standard sessions and is applied to any and all patients. Or has a standard formula for every session. Or standard home-based activities.
People and therapists are not monkeys. We don’t respond to the same process, format, style or approach. We also don’t work at the same pace. We don’t have the same issues or factors influencing our experiences.
As occupational therapists, physiotherapists, nurses, social workers, speech language therapists and others use CBT within their practice, we can offer distinctive flavours of therapy, and this means our clients/patients have a greater chance of finding something that works for them. What we must guard against is rote learning a series of questions or standard sessions and thinking that this is sufficient.
More on CBT tomorrow – and next week, some worksheets! Don’t forget you can subscribe via RSS feed (click the link at the top of the page), or bookmark this site. You’re always welcome to comment, and I’m happy to be contacted too. Just head to the ‘About’ page.