Working Generically:

Simple Goal orientated CBT

Simple goal orientated CBT

It seems there are several important staging posts in therapy that works with anxiety and depressive difficulties that have a specific goal.  This is quite specific therapy as not all therapy works like this as some might be more explorative of values and emotions.

1.       What’s the goal for treatment

Without this we don’t know where we are going or indeed the problem that gets in the way of the goal. Finding this out or not can indicate if goal orientated therapy is what is required.

2.       What is the problem(s) that get in the way of the goal?

Without this we don’t know what the obstacles that we need to tend to to achieve our goal.

3.       What keeps the problem going?

Important for a variety of reasons

·         to know how to treat

·         to understand the problem in more detail

·         to see the problem as having rationale, rather than an indication of deficiency which might be a way it could be interpreted by the client.

·         to make an ally with the resistance, we are not treating it as the bad thing to be got rid of, rather we are looking to understand it, and make sense of what keeps it around. We are listening to it

Types of things that keep problems going

·         Operant conditioning

o   What good stuff does the client get by their behaviour

o   What bad stuff does the client get taken away

This could be either emotionally, cognitively, or behaviourally

So, we might

·         remove unpleasant emotions

·         support beliefs about the world, so keep the world as understandable

·         get people to behave or stop behaving in ways that we want.

From understanding operant conditioning this will show us the maintenance model and how the behaviours are reinforced but leave intact the beliefs that underpin them. At this point we can see the perpetual motion of the problem where the operant conditioning doesn’t enable any learning to take place and the structure maintains as a self-supporting problem.  Indeed the standard problem in goal orientated clients seems to be they look to remove their symptoms, unpleasant anxiety, low mood etc, which in turn perpetuates their problem. So I feel low, reduce activity to avoid further pain and therefore stay low.

Standard maintainers

·         Anxiety

o   Avoidance (including safety behaviours)

o   Caught up in unhelpful thoughts\thinking patterns

·         Depression

o   Deactivation

o   Caught up in unhelpful thoughts\thinking patterns

·         Stress

o   Over or under doing

o   Caught up in unhelpful thoughts\thinking patterns

3.       What’s the motivation for treating the problem

There needs to be sufficient motivation for the client to work on the problem as it might be difficult at times. So, you need to know what makes the problem a problem, how does it get in the way of the life that you want. This question is one about values and consequences and effectively asks, how does the problem create effects that gets in the way of the life that is important to you and the consequence of its answer is motivation.

4.       Treatment

a.       Avoidance=exposure

b.       Deactivation=Activation

c.       Unhelpful thoughts=detach or challenge, mindfulness or cognitive restructuring

5.       Roadblocks

Once you get the formulation, you may well see it operating between you.  Client avoidance, self-critical thoughts or deactivation will operate in session and then the trick there, is to bring that into treatment. So instead of pointing to an out there of the therapy room where the problem and solutions exists, look and work with it in front of you.

6.       Process

Throughout all this work there needs to be the core conditions. Without kindness and empathy, the client isn’t going to feel safe to do something of the challenging things you might think are useful. Without feeling understood a client is unlikely to be fully engaged as they wont trust you.

Without feeling safe and trusting their therapist a client is likely to be reserved both in what they say and how they act. This would reduce engagement and co-operation

Without engagement and co-operation, they quite literally won’t be involved and as therapy works through them changing their understanding and behaviour, without their full engagement this won’t work, or at best will have a brief effect.

Summary

Goal orientated CBT seems simple by the above description. However, in my experience it can be, and it can be anything but.  What seems to make the biggest contribution to the difficulty is when the problem plays out in the room and isn’t attended to, and the way the client is worked with, the alliance that is formed, where the client doesn’t feel safe, understood and loved.