An Introduction to Cognitive Behaviour Therapy, 2 edition
Helping Clients Become Their Own Therapists
One of the most powerful components of the learning model of psychotherapy is that the patient begins to incorporate many of the therapeutic techniques of the therapist.
(Beck et al., 1979, p. 4)
In CBT we teach the client to become his own therapist, with the skills to manage relapse. Essentially, the cognitive therapist aims to make herself redundant, and this means thoroughly educating the client in the model and methods of CBT. There is more to this than simply sharing the cognitive model and strategies with clients. There are ways in which we can make therapeutic techniques more accessible and more memorable and ways in which we can prepare the client for independent long-term coping. In Chapter 3 we described how the therapeutic relationship is crucial in helping a client to explore and learn, and how collaboration is fundamental to learning the skills of CBT. This chapter will focus on ways in which client learning can be further enhanced and relapse management established.
Helping the client learn and remember
Clients cannot take on the role of therapist unless they can recall the model and methods of CBT. There are many models to explain learning, but perhaps one of the most relevant for us as therapists is the adult learning theory of Lewin (1946) and Kolb (1984).
Adult learning theory
This model emphasises the importance of experiential learning and the value of reflection. It comprises four necessary stages in effective learning:
These form a cycle as illustrated in Figure 6.1. For learning to be effective, it needs to move through all the stages of the cycle.
This understanding of the elements of effective learning can help therapists in many ways: for example, in deciding when to provide information and when to use Socratic method and in creating assignments to make learning more memorable. The next chapter focuses on the Socratic method, but it is worth noting here that the Socratic method contains elements of the learning cycle. When using it, we cue clients to observe on their experiences (observation); use this to develop new understandings of their problems (reflection); then synthesise new possibilities and ways forward (planning new experiences). Similarly, Chapters 8 and 9 focus on cognitive and behavioural techniques respectively, and you will again see how these crucial elements of CBT are linked by the learning cycle: cognitive techniques help the client develop new insights and possibilities (observation–reflection–planning) which are tested ‘in the field’ (experience).
Figure 6.1 The adult learning cycle (adapted from Lewin, 1946 and Kolb, 1984)
As an example of the learning cycle, you could present the model of cognitive therapy or illustrate the interactions of feelings, thoughts and actions in a way that takes the client around all four elements:
How did you feel?
Pretty anxious: I was scared.
And what was running through your mind?
I thought that I would embarrass myself – look like a fool.
So what did you do?
I told my boss that I couldn’t do the presentation because I would be on annual leave – I then booked in annual leave.
So you got out of doing the presentation: how did that leave you feeling and what was going through your mind then?
After the initial relief, I felt even worse. I still hadn’t faced my anxiety of public speaking and now I had the fear that my boss would realise that I’d lied to her.
It seems that you felt scared and you thought that you would embarrass your-self; so you avoided what frightened you but soon regretted it.
So, what might you learn from this?
I suppose it’s obvious really: if I get scared, I should face up to my fears. Running away is only making me feel worse about myself and I think that it makes me more anxious.
Facing up to your fears … do you have any thoughts on how you might go about doing that?
This could then lead to planning a behavioural experiment that would provide an experience that could be reviewed, and so on. This incorporation of experience and cognition has been shown to promote greater cognitive, affective and behavioural change than purely verbal interventions (Bennett-Levy, 2003) and to help to bridge the ‘thinking–believing gap’ that clients often experience (‘I know it with my head but I just don’t feel that it is so’) (Rachman & Hodgson, 1974).
It has been suggested that we each have preferences in the way that we use information and learn from it. Honey and Munford (1992) mapped these preferences on to the learning cycle and identified four preference types: activist, reflector, theorist and pragmatist. As you can see, they use the descriptive labels differently from Lewin and Kolb, which can be confusing. As you read through the descriptions of each stage in the cycle consider your own preferences.
The time of action, engagement, ‘doing’. This is the preferred quadrant of the activist, who enjoys being engaged in something tangible. Within therapy this might include role play or setting a behavioural assignment.
The part of the cycle where there is reflection upon what has happened: the preferred position of the reflector, who takes time to digest events and mull them over. In sessions this could include the process of reviewing a client’s thought diary or collecting feedback at the end of a meeting.
Making sense of what happened by relating it to previous experiences and knowledge. This analytical phase is preferred by the theorist, who enjoys searching for understanding. In therapy, this might be the process of reflecting back on the formulation of a problem, generalising from an experience or abstracting principles.
The phase when practical implications of a new understanding are considered, preferred by the pragmatist. This marks the time when plans are made, thus creating the basis for further experience. In therapy this is the time of preparing the next step, setting goals and tasks based on a new understanding.
Personal preferences can result in the under- or over-emphasising of elements of the cycle. For example:
- The activistmight dwell disproportionately on the ‘doing’ part of the task, for instance engaging a client in a behavioural assignment but then failing to review it thoroughly. This means that it is difficult to appreciate the implications of the experience and to take it forward. At worst, the experience is wasted.
- The reflectormight review the assignment but fail to make links with previous experiences or to generalise to develop principles. In this case, planning would be impaired as it could lack a theoretical basis and would be unlikely to make links with the client’s problem formulation.
- The theoristwill make links, but if observation is weak she will have little to work with. If the phase of planning is also weak, then meaningful future opportunities for learning can be lost.
- Finally, the pragmatistwill focus on creating concrete plans, but these will be less effective unless she is properly engaged in the active phase and the stages of observation and theorising. Unless all four phases are involved, even the best planning is unlikely to result in new skills being learnt or remembered.
Your own preferences might interact unhelpfully with the preferences of your client. For example, two reflector-theorists might have an agreeable and stimulating time philosophising but not be sufficiently active in therapy, so that experiential learning does not occur. Problems can also arise from an antagonistic combination, such as the activist–theorist therapist frustrated by the reflector or the pragmatist client, who might seem frustratingly slow or obsessive. Thus, in some instances, difference in preferences can underpin problems in the therapeutic alliance (see Chapter 3). Conversely, different preferences and styles can complement each other. An activist client can be encouraged to reflect and plan by a therapist with different preferences just as the activist–pragmatist therapist can build on the theorising of the ‘armchair’ client and help him better engage in behavioural experiments.
From the above, it is clear that learning style is relevant to training clients in cognitive therapy, and to the development of the therapeutic alliance. Therefore, it is worth taking time to reflect on it.
Learning is not just about acquiring knowledge; information also has to be retained and it has to be retrievable. Since clients need to be able to remember salient points from therapy, an understanding of memory and how we might help clients can be a valuable adjunct to our work. There are several useful resources for understanding more about memory and information-processing, but one of the most informative and readable is Alan Baddeley’s Your memory: a user’s guide (2004). This section owes much to this text.
The main systems involved in remembering are:
- Short-term memory (STM): This is the ‘temporary holding point’ for information (20–30 seconds): the information will be forgotten if it is not relevant or rehearsed enough to be transferred to long-term memory.
- Long-term memory (LTM): This is the ‘depot’, where information may be held indefinitely. Contrary to some beliefs, memory is not held like a recording that gets replayed when we recall something. It is more like a jigsaw puzzle, with the pieces being stored in different parts of the brain waiting to be reconstructed when we remember. This is an important point because it makes memory susceptible to distortion.
Is this important in clinical practice? Yes: the following example illustrates how understanding something about learning and memory can be relevant to helping a client get the most out of a technique.
Whilst learning a relaxation technique, a man reclines in a chair in his therapist’s office. His sensory memory processes verbal instruction, the tone of his therapist’s voice and the physical sensation of relaxing a body part or breathing slowly. This will be held in STM while the client carries out instructions and reflects on the effects of relaxation. If the exercises are considered relevant, they are then more likely to be stored in LTM.
If the exercises are not considered relevant, or are poorly attended to, they will be lost. Let us assume that the rationale for introducing relaxation exercises was initially persuasive and the client attended to the instructions, practised at home and returned to the session giving feedback on the experience. However, it emerged that his practice was not as the therapist expected. Although some elements of the regime had been remembered, parts had been forgotten and parts had been mixed up with other exercise instructions. Overall, the exercises had not been helpful. Discussion revealed what might have contributed to this.
- He did not remember the rationale for the exercises and so struggled to appreciate their relevance.
- The exercise had only been practised once in session, there had been little debriefing and nothing written down: thus he had formed a poor memory of the exercise.
- In trying to recall the relaxation exercise the client had unwittingly drawn on memories of yoga techniques learned years earlier, which disrupted his recollection.
- Both therapist and client tended towards the ‘activist’ quadrant of the learning cycle and were light on planning.
How might the client’s recall have been improved?
- Relevance: material that is perceived as important or meaningful is likely to be remembered. This is why sharing a rationale – and checking that the client understands and agrees with the rationale – is so important in therapy.
- Focus: distractions impair memory, so clients benefit from being focused. The therapist should minimise distraction and keep the client directed towards the task.
- Repetition: repeating information and experiences will render them more memorable. In this case, the therapist might usefully run through the relaxation exercise more than once.
- Active engagement: getting feedback from the client would also have helped. This would have prompted rehearsal of the information and encouraged the formation of personal links: subjectively relevant material is always more memorable than information that does not have personal associations.
- Memory aids: we all forget things, so we all benefit from notes, lists and so on. It might have been helpful to have given this client a handout restating the rationale and the techniques of relaxation, or to have recorded the exercise.
- Familiarity: we tend to ‘reorganise’ our memories in the light of previous experiences and beliefs (Bartlett, 1932). Therefore, it is useful if the therapist checks out the client’s responses to, and associations with, a particular technique. Often, previous experiences can helpfully be incorporated – in this example, familiar yoga techniques could have been structured into the exercises, making them more memorable.
- Working through the learning cycle: the client would have benefited from being cued to reflect on the exercise, consider what he had learnt and how he might take that forward. The conceptualisation and planning stages of the learning cycle offer an opportunity for trouble-shooting and for making concrete plans to practise.
Principles of effective learning apply to each of the cognitive and behavioural techniques we introduce to our clients, from simple diary-keeping through to complicated behavioural experiments. By using them you can help clients learn the skills of symptom management; but you also want your clients to be able to manage their difficulties in the longer term, and so they must also become skilled in relapse management. We turn to this now.
As stated earlier, clients must become independent of the therapist, and that means they need to remember the techniques of CBT and to be able to use them in difficult situations and to draw on them after a setback. It is crucial to long-term success that clients are able to tackle setbacks productively. You might wonder why this section is called relapse management rather than prevention. Although some treatment approaches might aim to have no relapses, it can be almost impossible to prevent some degree of relapse in some disorders and with some clients. Clients who anticipate that they can completely prevent relapse are therefore likely to be disappointed. However, it is possible to learn how to manage such events and to regain progress that has been lost.
Our recommendation is that relapse management is introduced early on in therapy so that it is developed as a skill that can be refined over the course of treatment. The most basic form of relapse management comprises three questions that the client asks himself following a setback:
- How can I make sense of this?
- What have I learnt from it?
- With hindsight, what would I do differently?
In this way, your client develops the habit of analysing and profiting from setbacks. For example:
Carol struggled with an eating disorder and had periods of binge-eating. One evening she bought quite large quantities of her favourite foods, went home alone and consumed it, only spitting out chewed mouthfuls when she became over-full, but unable to stop eating. During this time she could not stop herself. Such an evening would usually have marked the beginning of a significant decline. She would have woken the next day feeling physically unwell and uncomfortable, she would have concluded that she was a hopeless failure and her mood would certainly have been depressed. As a ‘hopeless failure’ she would have felt powerless to resist the urge to comfort eat. However, on this occasion, she asked herself:
- How can I make sense of this lapse? She realised that she had been feeling stressed at work for several days but had kept pushing herself in order not to think about her troubled relationship. In addition, she had begun to resume her old habit of starving throughout the day in an attempt to lose weight. Once she had reflected on her situation, she was then able to say: ‘It’s no wonder that I fell off the wagon. Not only was I stressed to breaking point but I set myself up for a binge by not eating during the day.’
- What have I learnt from it? ‘I realise that, for me, it is dangerous to starve as a means of weight control – it backfires. Also, I need to keep a check on my stress level: when it gets too high I am vulnerable to comfort eating.’
- With hindsight, what would I do differently? ‘Hard as it is, I would try to eat “sensibly” and avoid starving. Looking back, I made a mistake in trying to pretend that I did not have problems in my relationship and then throwing myself into my work as a distraction. If I had that time over again I would acknowledge my problems, or maybe even talk to someone about them rather than ignoring them.’
Not only does this give Carol a plan for coping in the future, but she has learnt more about her particular needs and vulnerabilities. With each setback she will be able to continue to ‘fine-tune’ her understanding of difficulties and develop a wider and more individually tailored repertoire of coping responses.
The pioneers of relapse work in CBT are Marlatt and Gordon (1985), who first developed their model and strategies in the treatment of addictive behaviours. However, their understanding of relapse risk and management has proven to be relevant across psychological disorders (Witkiewitz & Marlatt, 2007). They identified several factors that rendered clients vulnerable to relapse. A particularly potent one was a dichotomous, or ‘all or nothing’, interpretation of a setback. They observed that clients who perceived themselves as either being in control or having failed tended to relapse at the first sign of difficulty: these clients flipped from feeling in control to feeling as though they had failed completely. Once in the ‘failure’ mindset, they tended to be dominated by a sense of hopelessness which drove unhelpful behaviours such as continuing to drink for comfort. Instead, Marlatt and Gordon encouraged them to develop a continuous notion of being in control and slipping out of control, which could accommodate minor and even significant setbacks without the client automatically assuming failure (see Figure 6.2).
Holding onto this model of a spectrum of experiences between control and perceived failure increased the likelihood that a slip or a setback would be perceived as a temporary aberration which could be corrected. To further encourage resilience, clients would be urged to consider the different stages along the continuum and to ask:
- When will I be at risk of this happening?
- What are the signs?
- What could I do to avoid losing control?
- What could I do if I did lose control (damage limitation)?
In this way, clients can recognise ‘early warning signs’ and try to avert a lapse, whilst still having a well-considered back-up plan. Thus, a lapse can be construed as an anticipated event for which there is a solution.
Figure 6.2 The dichotomous and the continuous view of control
What factors besides dichotomous thinking predisposes a person to relapse? Marlatt and Gordon identified a sequence of events that systematically increased the likelihood of relapse. These were:
- Being in a high-risk situation: for example, a depressed person being socially isolated, or someone with an eating disorder not having eaten for too long.
- Having poor or no coping strategies: for example, poor mood management skills or no helpful ideas for dealing with hunger pangs in a controlled way.
- The sense of loss of self-efficacy: for example, thinking ‘I’m hopeless. It’s my fault that I’m depressed,’ or ‘There’s no point in trying to resist. I just can’t.’ Such thoughts give a person ‘permission’ to let go or give in. This step can be exacerbated by substance misuse.
- Engaging in unhelpful behaviours: for example, withdrawing further or binge-eating.
In Marlatt and Gordon’s view, the worst was still to come: they recognised that many clients who were striving to remain abstinent from problem behaviours became caught up in a powerful cycle of unhelpful thoughts and behaviours once they ceased to be abstinent. They called this the ‘Abstinence Violation Effect’ (AVE) and saw this as marking true relapse – a state of not being able to break away from the problem behaviours because of compelling negative thoughts (see Figure 6.3).
Figure 6.3 The relapse cycle
An advantage of identifying the steps en route to the AVE is that they offer clear points for interventions which can interrupt progress towards relapse. As memory and performance are often impaired in distress, it is advisable to encourage your clients to write down their personal plan for minimising relapse and to make sure that they have easy access to it, of course. Below we lay out some strategies for each of the steps towards relapse:
- Being in a high-risk situation: The key is to identify (through monitoring), predict and, where possible, avoid high-risk situations. For example, if a depressed person learns he is at risk of becoming miserable when socially isolated, he needs to strive to maintain social contacts; if a woman with an eating disorder is at risk of binge-eating when over-stressed or hungry, she needs to avoid getting into those situations. However, difficult circumstances are sometimes unavoidable, so vulnerable clients may find themselves in a high-risk situation. This does not make relapse inevitable, although it is more likely if the client has poor coping strategies or has grown increasingly ambivalent about change (in which case it may be helpful to try to re-motivate clients by using a motivational interviewing approach: see Miller & Rollnick, 2002 or Rollnick, Miller & Butler, 2008).
- Having poor or no coping strategies: Clients are encouraged to develop appropriate cognitive and behavioural coping strategies and to plan how they would put the strategies into action. Although this is a routine part of their CBT, it is helpful for clients to keep reminders of what works for them, which they can access at times of need when their memory might be impaired by their emotional state. Someone prone to depression might list all the social activities and contacts he could try if he felt vulnerable; the woman at risk of binge-eating might keep a reminder of the activities that curb her urge to binge.
- The sense of loss of self-efficacy: This is a very cognitive element in the course of relapse, and therefore CBT is well placed to help clients develop realistically hopeful and empowered self-statements. For example: ‘It is my way of thinking that is bringing me down, but tough as it is I can “coach” myself out of it again. Furthermore, there are a lot of friends out there who want to support me,’ or, ‘I can resist. I have resisted in the past. I am not saying that it is easy but I know that it’s possible for me.’ Again, clients need to anticipate when they are likely to use such statements, and it can be helpful to rehearse using them either in role play or in imagination. This also affords the therapist an opportunity to check that the self-statements are not unhelpfully bullying or critical.
- Engaging in the unhelpful behaviour: for example, withdrawing further from social activity, or binge-eating. As you saw in Figure 6.3, clients can get locked in a powerful and unhelpful cognitive–behavioural cycle. You can use techniques of cognitive restructuring (Chapter 8) to break the pattern and to support behavioural change (Chapter 9), which will in turn provide support for further cognitive reappraisal. This is illustrated in the examples in Figure 6.4. Clearly the more ambivalent the client, the more difficult it might be to generate such helpful statements.
It is worth noting that ambivalence about change (which is discussed more fully in Chapter 11, on the course of therapy) can render a person even more vulnerable to lapses and relapse, and you need to keep track of your client’s motivation to change.
Figure 6.4 Breaking the relapse cycle
‘Self-help’ reading (bibliotherapy)
Your clients’ progress and maintenance can be enhanced by their reading relevant literature. Chapter 16 reviews different methods of delivery of CBT, amongst which is bibliotherapy. If you are intending to supplement CBT with such literature, do make sure that you have read the booklets or books yourself, so that you can evaluate the quality or demands of the text before you recommend them to clients.
Therapist maintains role of expert; client strives to remain a patient
First, discover what assumptions might be relevant to this problem: what makes sense of it? For example, perhaps you are thinking: ‘I have to know more than the client in order be competent’; or the client believes, ‘I can never help myself, so there’s no point in trying’. The obvious next step is evaluating and challenging such unhelpful assumptions. Use supervision (self, peer or expert) to help clarify and rectify this type of impasse.
Course of therapy not reflecting the learning cycle
Review your, and your client’s, learning styles and preferences and, if appropriate, use supervision to discuss the possible impact on your work and ways of overcoming problems.
The client wants to be ‘fixed’ or ‘parented’
Some clients do not readily take to the idea of collaboration and self-help. Sometimes, a few sessions of socialising your client into the ways of CBT will be sufficient to shift his expectations of passivity or long-term care. However, there will be those who continue to find the goal of self-help unappealing, or even frightening. Try to uncover the assumptions that explain this attitude – assumptions that might have to be tackled before your client can engage in CBT. This can take some time, and you need to ask yourself if you have the time and the skill needed to do this (see Chapter 17 for more discussion of working with complex clients). In any case, an essential guideline is to review regularly. Clarify unhelpful patterns, and if it is not possible for you to help your client with CBT, then consider referral to a therapy that better meets their needs at this stage. For example, supportive counselling might be better for some clients or a more obviously inter-personally focused therapy, such as cognitive analytic therapy (CAT).
Relapse management is reserved until the end of treatment
Awareness of personal vulnerability and its management is relevant from the onset of therapy. Try to build this into early sessions by asking: ‘When can you imagine struggling with this?’ or, ‘When do you see yourself being at risk of having a setback?’ If your client has a lapse, use the opportunity to review this thoroughly (setting aside enough time to do so), encouraging your client to learn from setbacks early on in your work together.
Therapist feels pressured and skimps on relapse management
Relapse management is an investment of time, but it is a worthwhile investment as it can save your client the distresses of relapse and it can save your organisation the cost of offering further treatment. If your client cannot see trouble coming or handle it when it arrives, then he will be vulnerable to relapse – even if he is otherwise skilled in cognitive and behavioural techniques.
An over-arching goal of the cognitive therapist is to ensure that the client becomes his own therapist. We aim to make ourselves redundant by communicating the knowledge and skills necessary to maintain progress and minimise relapse. We can do this most effectively if we attend to the principles of adult learning theory and memory, and if we invest time in addressing relapse management.
- Adult learning theory reminds us to attend to the strengths and preferences both we and our clients show when encountering new information. It also reminds us to be conscientious in encouraging clients to spend time in each ‘quadrant’ of the learning cycle:
o reflecting and making links with previous knowledge and developing new ideas
o problem-solving and thinking how to take things forward
o creating active experiences.
- Models of memory remind us of the importance of maintaining focus, encouraging rehearsal of new material, emphasising its relevance, using memory aids and exploiting familiarity with previous experiences and knowledge.
- Relapse management is the key to continued progress and its concepts really need to be introduced from the beginning of treatment so that clients have good opportunity to develop the ability to learn how to learn from their setbacks.
Review and reflection:
- Note what strikes you as being particularly interesting or important in this chapter: how you are going to remember this?
- How do learning theory or memory processes fit with yourunderstanding of CBT – do they make sense when you consider them in the context of your work? How do they fit with yourexperiences of having to remember procedures and protocols or the difficulties your clients have in recalling things from one session to the next?
- How does relapse management fit with your experience of dealing with setbacks, either personally or with your clients? Does it seem like a valid approach?
Taking it forward:
- Learn more about your learning style, perhaps by completing a learning styles questionnaire (see Honey & Mumford, 1992), or by recording your sessions and observing how you interact with different patients.
- Learn more about memory by reading more on this topic (for example, Baddeley, 2004) or by signing up for a relevant course or a workshop.
- Plan your clinical sessions in order to enhance memory (both yours and your client’s!) and to get the most out of your learning style.
- If relapse management is a particularly pertinent section for you, update your reading (see below); you could introduce it in your sessions and evaluate its impact on client progress. Review with your supervisor your attention to helping your client become his own therapist, to ensure that you keep this in mind.
Baddeley, A. (2004). Your memory: a user’s guide (2nd ed.). London: Carlton Books.
An excellent introduction to memory, written by a leading expert who knows how to communicate with the lay person as well as the specialist. It is a classic work, really well researched and informed yet not at all difficult to read and highly relevant to our work as client coaches and trainers.
Honey, P., & Mumford, A. (1992). The manual of learning styles. Maidenhead: Peter Honey and Associates.
This is the manual which explains and helps you evaluate your learning style. It has been in use now for nearly twenty years, which gives you an idea of how helpful it has been. It is rather expensive though, and perhaps only for those who need a detailed analysis of their learning style.
Witkiewitz, K., & Marlatt, G.A. (2007). Therapist’s guide to evidence-based relapse prevention. Burlington, MA: Elsevier.
This is one of the few relapse prevention texts that cover a range of psychological problems, rather than simply substance misuse. Invited authors address eating disorders, mood disorders and PTSD, for example. Marlatt was key in developing relapse preventions models and methods over 25 years ago, so he brings a huge amount of knowledge and experience to this edited text.