Sunday, 10 June 2012

How Not to do CBT - part 1

It's far from true to say that CBT is just about applying a few techniques. In fact, good CBT requires a lot of knowledge and a lot of skills, including the ability to put these all together when in the company of a client.
In this article series I will be sharing some ideas about how to do CBT - and first, how not to do CBT, with a hypothetical client, "John".  Hopefully it will be useful.

John comes to CBT because of his depression.  He is a 40 year old who has recently been made redundant. He is worried about getting a job again and his redundancy has also  caused tension in his marriage. When questioned about how he spends his time now, he says he gets up late, intends to look for jobs but ends up doing very little. He feels demotivated, discouraged and, at times, hopeless.  He is having trouble sleeping and hints that he may be using drinking to cope with his difficulties.  At times, he says, he wonders if he will ever get a job again.  He sees his redundancy as meaning that he is a failure.  He talks in  a flat, slow monotone. As he talks, he is becoming more sad and more hopeless.

How NOT to do CBT:   Counsellor/Therapist  A with "John"

A1: (In a very empathic tone). Good to see you again, John , how has your week been?
J1: Well, up and down.
A2: (Sits in silence, waiting for more)
J2: I still haven’t got a job. I still waste most of my time.  I still think I’m a waste of space ….
A3: Sounds like it’s been a tough week.
J3: To be honest, I’m not sure if this counselling is helping.  I wasn’t sure whether to come, but my wife insisted. (Sits in silence)
A4: So you weren’t sure whether it was worth you coming or not?
J4: Well, I’m not better yet, am I?
A5:  I’m really sorry that you aren’t feeling much better. What’s the main thing that’s been on your mind?
J5: I don’t see any prospects of getting work. I’m not getting any younger, the economy is getting worse. Be honest, would you employ a sick 40 year old if you could take on a healthy, cheaper 30 year old?  My mate Dave said “treat it like a holiday” but I’m telling you, it’s no holiday.  Or if it is, it’s a holiday from hell. My wife hardly talks to me, except to make digs at me.  I just don’t see any future.
A6: (increasingly feeling engulfed in John’s depressed mood) I can see why you do feel hopeless.
A7 (Remembering they are meant to be doing CBT not general counselling) I can see it is all looking hopeless now, but sometimes when people are depressed they think in rather extreme and unhelpful ways. It’s like putting on a pair of glasses that filters out all the good things. Do you think that might be happening to you?
J6: I suppose so.
A8: So, what would it be like for us right now to try on a pair of more rose-tinted spectacles and see what your life might look like?
J7: Right, like in those self-help books – “think yourself to happiness!” (Smiles ironically). No thanks, tried that.  I’m afraid with me the situation really is bleak it’s not just my thinking.  Maybe I was right after all in thinking that this approach isn’t going to help me.

Can you see what is wrong with counsellor A's approach?

What tips would you give him or her?