The well-loved British TV presenter David Dickinson is best known for his various antiques programmes, and most widely recognised by his skin colour — sometimes (wrongly) thought to be fake tan…or even furniture polish. But my favourite moment from his TV career was a programme that got under his skin in a most unexpected way, a way that reveals much about the present practice of CBT.
Star portraits
The programme was Star Portraits with Rolf Harris, in which a different TV celebrity each week had portraits painted by three artists. We saw an initial sitting when the artists made their first sketches, followed by something of the artists’ methods of working. Finally, the finished portraits were unveiled to the celebrity, who would choose one to keep.
The connection with psychotherapy is that many of the portraits in the series revealed so much about the personality and feelings of the subject. Yet the artists had had relatively little direct contact (working mainly from photographs). David Dickinson’s emotional connection to one of his portraits was particularly strong.
The real art of portrait painting is not in knowing how to mix paint and where to dab it. It is in getting under the skin of your subject and reflecting that in the finished work.
Your own portrait
If you would like to have the kind of experience that David Dickinson and the others had — to see yourself as another person sees you, with real self-recognition and a deep emotional connection to your portrait — how can you go about it?
One way might be to read a book about the techniques of portrait painting, or even many books. But I hope it’s obvious that reading books about painting technique cannot possibly acheive the desired result. You can read and read all you want, but no paint will ever touch canvas that way.
Another way might be to attend painting classes. That way at least some painting will happen. But again it misses the point. After many years you might be able to paint a great self-portrait, but it still tells you nothing about the person others see in you today.
Perhaps the computer photo-fit techniques that police forces use are the answer. Someone who knows you could make a photo-fit likeness, then that could easily be converted into a paint-by-numbers kit, and finally a painter with relatively little skill could apply the paint. It’s likely, though, that the result will disappoint by failing to capture any emotional connection.
You might have no alternative but to find a talented artist.
Parallels
In CBT, too, people try various approaches. Their approaches to CBT have parallels in the approaches to portrait-painting above. There are people who read books about CBT techniques, therapists who in effect run classes, self-help books and websites that adopt a formulaic approach, and skilled psychotherapists who connect deeply with their clients:
| Read about CBT techniques | = | Read about painting techniques |
| Attend a CBT course | = | Attend portrait-painting classes |
| Use a CBT self-help course | = | Use photo-fit and paint-by-numbers |
| See a skilled psychotherapist | = | Sit for a talented artist |
Steps and semantics
The difference, though, is that some patients who have never been treated by a skilled psychotherapist think that they have done CBT. It’s OK if you try a version of CBT, and if it doesn’t work you move on to a more authentic version. It’s not OK if you try a version of CBT that doesn’t work for you, then you just give up. In treatment planning, trying something simple and then moving on to something more complex if it doesn’t work is known as stepped care.
Part of the problem is semantic. There are no good simple words to describe authentic skilled-psychotherapist CBT so as to distinguish it from less effective versions. The latest term in the UK seems to be high-intensity CBT, but I’m not sure that its precise meaning will be obvious to most patients.
Examples
I’ve been seeing some examples in the blogosphere recently.
Peg, commenting on CBT Is Not the Only Effective Therapy, suggests that CBT is something you can learn by yourself, (and that therapists feel threatened by this).
Melissa, in Learning to Live in Shades of Gray, describes a therapist whose CBT looks like it might be the paint-by-numbers type. This therapist does not seem to be trying to know Melissa well and discover with her the root cause of her problems. Instead she seems to be addressing each symptom as a separate area to colour-in.
I hope that Peg, Melissa, and others like them have found versions of CBT that work for them. But if they haven’t, then I hope that they remember the stepped-care model, and move on to the next step.
Hi–I am Melissa, of “Learning to Live in Shades of Gray” and she and I discussed the options: getting to the root of why I am the way I am (which she contends is my “hardware”–as an anxious person) or to use CBT methods to help change my thinking that leads to my disordered behaviors. I was more interested in CBT.
That said, she admitted last night that since I am also OCD, CBT alone might not be enough. I do feel like she’s trying to get to know me–we have only met twice (once last week, and once this week). I really hope you’ll give her the benefit of the doubt and allow her to work with me. Each symptom, to me, is part of the bigger picture.
In the end, my goal is to be less anxious and less OCD. The root cause of my problems seems to be my hardware–that I’m an anxious person. And her philosophy is that a person’s hardware doesn’t change. You can add new software to run better, but the overall hardware is the same.