I wanted to elaborate on a bit of my post from yesterday. I mentioned transactional analysis, partly because it fit the topic and partly because I just finished an assignment comparing it to Beckian CBT. My personal view on counselling/psychotherapy approaches is that none of them explain how mental illness develops. Many of them describe part of the picture, and some are more holistic than others, taking genetics, environment and the interplay between the two into account. But I am not and probably never will be drawn to one theory, because I’ve never met a theory which explains everything I would want explaining.
I’ve been thinking a lot about theories and the way I would describe my own orientation lately because of my looming placement. I like, see sense in and will defend CBT when I see people spouting half baked myths about it or dismissing it out of hand, because usually that comes from a place of either having had a bad experience with NHS-style CBT (otherwise known as “throw worksheets at a person for six weeks and hope something sticks”) or having heard of others’ bad experiences with it and therefore believing that CBT as a whole is a crappy little sticking plaster. This is a justifiable reaction if either yourself or someone you care about has been invalidated by some robotic mental health professional, but what you’re really pissed off about is the government’s misappropriation and dilution of a complex and interesting theory for the sake of budgets and outcome measures. I like CBT because, after years of psychodynamically informed therapies in which I was systematically invalidated and left sicker than I started, I eventually CBT’d myself without knowing what I was doing. When I started recovery I picked my eating disorder to shreds. I had more than enough experience of attempting to find “root causes” and had come to the conclusion that my environment had played far too complex a part to be distilled down to a simple phrase about controlling parents or fear of growing up. Instead, I evaluated the things which had led to relapses in the past, and the thoughts/anxieties I had when I tried to consider recovery. I came up with the list in this post (here), each point of which I broke down further and worked on with my therapist at the time. I also actively worked on my motivation, and I credit things like my recovery flashcards (geek!) with keeping me going rather than falling at the first panic attack or week of weight gain.
What people also don’t realise about CBT (because they’ve never been told about anything other than the superficial stuff) is that it deals with pretty much the same concepts at the same depth as any other theory, just using different terminology. According to Judith Beck, therapy often needs to start at a fairly superficial level (dealing with negative automatic thoughts – patterns of thoughts people have in response to certain situations which result in them feeling more anxious or upset about it, in a nutshell) so as not to overwhelm clients and to help them learn a few coping skills before progressing further into more challenging and potentially traumatic territory. Or to use myself as an example, when I was in therapy in 2009 my therapist (humanistic, not CBT) supported me through weight gain and some of the more superficial fears I had about that, helped me learn coping skills and THEN, when I was healthy and stable enough, we dealt with my PTSD from being raped. Trying to do things the other way around would have left me retraumatised and unable to cope. Deeper CBT concepts like core beliefs and schemas are similar to Rogerian conditions of worth, TA life scripts and transitional objects in object relations. All are related to the way which infants and young children make sense of a world they lack the language to make sense of, and in all cases bringing these concepts into the conscious awareness of the client is supposed to help them understand why they are as they are and therefore change.
Personally, I don’t think awareness, insight and understanding are enough for change. I don’t think a warm therapeutic relationship is enough for change. I don’t think challenging thoughts on an intellectual level is enough for change. I don’t know what IS enough for change, but I don’t think any of the current counselling theories are holistic enough. I want to play pick n mix. I like the humanistic way of fostering a therapeutic relationship with empathy, unconditional positive regard and congruence. I like a lot of CBT techniques, and I unwittingly used many of them in my own recovery. There are a few psychodynamic concepts like transference which I will use, because I think it is entirely common sense to evaluate the ways in which the client may be re-enacting their general relationship patterns within therapy. I think transactional analysis (largely humanistic, although with similarities to CBT and psychodynamics) has lots of great ideas about the maladaptive patterns of behaviour people can get into in their interpersonal relationships. I love mindfulness, and I’m a total geek for biology.
Why be reductive? None of these theories explain human nature in its entirety. None of them fully account for the development of mental illness, or the alleviation of its distress. I don’t want to be the sort of haphazard, no idea what I’m doing eclectic therapist I’ve sometimes come across when seeking help, but I am certainly not going to squash clients into boxes I don’t see anyone else fitting into either. On placement, I’ll use whatever I get a gut feeling the client might relate to and find helpful. I’m not there to tell them what to eat, what to weigh, how their parents or society fucked them up, how eating disorders develop. I’m not a specialist psychiatrist, or a dietician, or a chemist, or a geneticist. I will try to support people in removing their barriers to living the life they want to lead. That’s really all I can do.
That’s my sort of approach.