Cognitive Behaviour Therapy is too rigid, right?

reith gawande







BBC Reith Lectures

I was listening to the excellent 2014 Reith Lectures by Dr Atul Gawande, and in particular I was struck by his 2nd lecture ‘The Century Of The System’. During the lecture, DR Gawande describes a complex medical case in which a 3 year old girl fell through ice into a fish pond and drowned. Despite being underwater for 30 minutes, and despite being in surgery for almost 48 hours and in a coma for over one week, the girl survived.

Exploring how the girl survived, Dr Gawande describes a complicated system of steps and processes which must be followed in order to provide the best chances for a patient in this situation to pull through. The little girl in question drowned near a hospital in Austria in which this type of drowning incident had occurred intermittently in the past. In response to these past incidents, systems had been designed, processes developed and best practices put in place. All of the staff who were needed to deal with the drowning were present at the correct times, all the stages of resuscitation were pre planned, and the necessary equipment was already in place for just such an occasion. The hospital had a team prepared to deal with this type of trauma; the system had been designed over many years through trial and error. A check-list was drawn up to support the system, and a telephone operator, not a member of the medical team, was in charge of ensuring this check-list was adhered to. Within each stage of the process, the individual members of the medical team had a role to play, they might have been required to improvise or make changes depending on the response of the patient, but overall everyone knew what their job was, what their goals where, and at what stage of the process they would be deployed.
For me, this kind of systematic approach gets to the heart of what CBT is and why it works. CBT is a framework as opposed to a prescriptive way of working. In my experience, no two clients are ever the same, and as such no two treatment plans would ever be the same. CBT is about looking at tried and tested methods of working with clients, it is about using processes which have worked in the past as a roadmap for working in the present and as such it is an evidence based approach. When I am working with a client, I am looking at what research has told me will give me the best chances of helping my client, but during sessions I am having a conversation with an individual. We are looking at their uniqueness, we are uncovering the possible reasons for their thoughts or behaviours, together we are trying to formulate a deep understanding of what is going on, and wherever possible I am allowing the client to find their own answers. The therapeutic process is fluid and unpredictable, but how I approach each client’s overall treatment is systematic. By having a systematic approach, I can ensure that wherever possible I am using what has a proven track record of being successful in the past, and providing this service to my client should mean I am creating the environment for the best possible chances of success in the present.
When I hear people talking about CBT and how they have tried it and it never worked for them, they tend to go on to describe something which bears no resemblance to what I understand cognitive behaviour therapy to be. I have heard people talking about completing homework for homework’s sake, situations in which the client is being asked to do something without understanding the purpose of the exercise. I have heard people talk about goals being set by the therapist instead of the client. I have heard people describe situations in which they haven’t talked about their current feelings with their therapist, or they have never really discussed the past in order to provide context. These aren’t examples of bad CBT, in my mind these are all examples of poor therapeutic practice in general.
For me, therapy is about finding out the how and why we do what we do, and then giving ourselves the chance to do something different. It is about hope and optimism, about breaking free from the constraints we have placed on ourselves. It is about imagining a better ‘me’, and learning how we can make changes that we find helpful. It is about accepting who we are and what has happened in the past, about being able to live with ourselves and find peace. CBT should be about providing a framework for all of this to happen, it should be about providing tools to allow us to make the changes we want, while at the same time accepting who we are and our place in the world. It should be able to provide a way to practice new ways of being, to practice new behaviours in a safe environment. CBT should allow us to understand why we are the way we are, while at the same time offering options which allow us to make the changes we want to make. As far as I can tell, these should be goals for all therapeutic practices, but they are certainly goals I hold for my clients.


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