Sunday, 17 June 2012

How Not to Do CBT - Part 2

In part 1 of this series I showed one way that CBT can go wrong. In this post I will illustrate that there is more than one road to a therapy train crash! Here is a reminder of the client.
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  B with John

B1: (In a business-like tone) Welcome back  John, This is session 3 and today we are going to look at how being more active can help you be less depressed.  Have you got your homework with you?
J1: Yes (Gets sheet out of pocket) – here it is.
B2: Right, so let’s see. Good, so on Wednesday you were more active and felt better. On Thursday you didn’t do much and felt worse. This supports what we know to be true in general, which is that when we are active we feel better and when we are less active we feel worse. Make sense?
J2: I guess so.
B3: There’s what we call a vicious cycle of depression (Shows John handout  “Vicious Circle of depression” ). I’d like you to read this sheet as part of your homework, OK?
J3: Yes.
B4: So what we need to do is work out how we can get you more active in the next week.  Do you ever go jogging?
J4: Not much.
B5: Swimming?
J5: No
B6: How about talking to friends?
J6: Well to be honest I haven’t felt much like doing those things much.
B6: Well, as homework for this week I’m going to suggest you commit to one activity each day. What are you going to do today?
J7: (Smiles)
B7: I’m glad to see you smiling. Are you thinking of something enjoyable you are planning to do?
J8; No, I was thinking of that old Sinead O’Connor song, “Nothing Compares to you”. Remember the line “went to the doctor …he said girl you better try to have fun no matter what you do
but he's a fool.”
B8 (a bit annoyed) It’s not foolish to ask you to do more – there’s a lot of evidence that backs it up!
J9: (smiling again) And does everyone get better when given a dose of your CBT medicine?
B9: No, of course not, not everybody, there are exceptions …
J10:  The hopeless cases, right. Well look at me  - old, unemployable, broken marriage –ready  for the scrapheap of life. Best save your medicine for a less hopeless case, don’t you think, doc?

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

What tips would you give him or her?