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.
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