A recent research study that asked CBT therapists to reflect on their own thoughts illustrates unwittingly how poor some CBT training has become.
Three New Zealanders, none of them accredited CBT therapists in the UK, have nevertheless had an article published in one of the BABCP’s two research journals, Behavioural and Cognitive Psychotherapy. In line with most other academic research, this journal is not freely available to the public, allowing academics to spend other people’s money for almost no practical or theoretical benefit in almost total secrecy.
The article purports to be about case conceptualization, the process of working out the specific cause of an individual patient’s illness so that it can be treated. In line with most other academic research, there are no useful conclusions. No actual conceptualizations of actual cases were involved at any stage of the research. The whole thing is entirely conjecture: Improving the Quality of Cognitive Behaviour Therapy Case Conceptualization: The Role of Self-Practice/Self-Reflection
However, doing research into case conceptualization without conceptualizing any cases poses an interesting problem. What do you do instead? The choice of what to do instead reveals what the researchers and participants really think CBT is all about.
Self-practice
At the heart of this research is the idea of self-practice. Sixteen qualified therapists were encouraged to perform a kind of fantasy CBT on themselves using a specially designed workbook.
Of course, such a thing is clearly nonsense. Psychotherapy is designed to be used to treat mental illness. In the absence of any mental illness, there can be no psychotherapy.
And psychotherapy is designed to rely on an observer’s perspective of the patient’s mental state. In the absence of any observer perspective, when someone merely reflects on their own mental state, there can be no psychotherapy.
Generalizations
While real life case conceptualization results in a very specific treatment plan, the fantasy self-practice that participants indulged in resulted only in generalizations. The therapists were encouraged to reflect by answering questions [sic] like (page 327):
Comment on how it felt to process your thoughts in this way?
Mary, for example, is said to have reflected as follows, neither she, the researchers nor the journal’s editors attempting to make grammatical sense of her ramblings (page 328):
I don’t learn from similar experiences all that well. That I tend to act like this without thinking and then reflect on how I should have responded afterwards.
And Angela (page 329, original emphasis):
Enlightening completing the schema questionnaires and I enjoyed this part of the study the most as it gives me a sense of where I can challenge myself. Fits well with unrelenting standards.
Veronica, who had been so depressed two years previously that she could not go to work, apparently learned to understand her core beliefs (page 330):
I am glad they are fully exposed now (core beliefs) I don’t have to try so hard as to stress myself up to do my work and be a little more caring of myself.
Veronica’s example is the most revealing, because we never learn what these core beliefs are, or why their being “exposed” makes her glad. Neither she nor the researchers seem to have any interest in taking these generalizations further and getting anywhere close to what might reasonably be called conceptualization.
Empathy
After this, the paper loses its way entirely and gives up any attempt to address case conceptualization. There is a confused section on empathy. Here’s Veronica again (page 330):
I can relate to the difficulty and pain of people who have depression and anxiety disorders, low self esteem etc…
And Helen (page 330):
It reminded me of the bravery and difficulty in examining one’s beliefs.
This is not empathy, of course. It’s sympathy. That is, these feelings that Veronica and Helen describe are not real feelings they have in relation to any particular person. They are not a genuine mirroring of another human being’s emotional state. They are are just narcissistic fantasies based on their own emotional states.
Childhood
A section on memories of childhood is similar. Mary found it difficult to remember specific things about her childhood, but she was able to conclude (page 333):
It has made me more sensitive to the connections between childhood experiences, the schema.
No actual connections are mentioned, and as she found it difficult to remember anything, it is hard to believe that she was able to make any connections, never mind identify schemas.
Personal conceptualization
A section with no heading appears to deal with making a personal case conceptualization. It is not clear what this means, because no example is given, and none of the quotes refers to this personal case conceptualization.
However, this section contains some disturbing statements made by participants about the way they behave towards their patients. For example, Jennifer (page 333):
I have tended to avoid case conceptualization in the past or at least avoided sharing them with clients as they seemed a bit harsh, whereas in reality clients might enjoy/be interested in/relieved etc to understand themselves in this way.
And an unnamed participant wrote (page 334):
It reinforced the importance of providing not just a lip service of CBT. Mental health service demands e.g. waiting lists and pressure to treat and discharge clients, can I believe “short change” some clients of full treatment.
Criticism
One participant, Joan, criticized the fantasy CBT self-practice exercises (page 335):
…I am not sure that I know or can make any conclusions about the results that are meaningful or have currency for me.
The researchers retaliated by criticizing Joan (page 335):
…there may be some cause for concern regarding the way in which she would process client’s [sic] emotions[.]
Then they took a swipe at her again on a later page, referring to (page 337):
…Joan, who “got lost”…
Piggybacking
To improve its position in the search rankings, as it were, the paper includes the names Kuyken, Padesky and Dudley in the abstract, attempting to piggyback on the success of the book, Collaborative Case Conceptualization, which I reviewed in Reliability. The connections between the book and the research can only be described as shallow at best.
For example, one of the book’s most memorable features is its use of boxes captioned “INSIDE THE THERAPIST’S HEAD“, which show over and over again that a therapist’s own thought processes are distinct from (though closely related to) the therapist’s interaction with the patient. It is difficult to believe that anyone who reads the book could possibly miss this. Yet these researchers created self-reflection exercises in which there is no such distinction.
And again, while the book does mention reflective learning, it does so in relation to clinical practice (page 256):
Reflective learning describes what goes on when therapists stand back from their clinical practice and observe what has happened in order to improve knowledge, skills and therapeutic behavior.
In the book’s example of this, Theresa is a therapist treating Joe. She reflects on her sessions with Joe to understand why they make her feel fatigued. Her reflections are specific and detailed (page 277):
Theresa noticed that Joe’s vocal tone and patterns of complaint evoked images of her older brother, Pete.
Yet these researchers devised a form of reflection that is unrelated to observing what has happened in clinical practice, focusing instead on therapists’ feelings about themselves. And instead of being specific and detailed, the reflections in the research are vague and general.
From its very first page, and throughout every chapter, the book warns against unquestioning belief in pre-existing models. For example, (page 69):
…it is important that the therapist be equally attentive and curious regarding client observations that fit and do not fit the model. Otherwise, expressed curiosity is a thinly veiled method for convincing the client of a therapist’s belief…
Yet in the research study Joan’s findings that the pre-existing model in the workbook did not fit her caused a backlash from the researchers.
Implications
There is nothing very significant about the conclusions of this almost meaningless research paper, but it illustrates how an idea like case conceptualization can be digested and excreted in an unrecognizable form by academics.
Case conceptualization is intended to be a well-defined process for determining the nature of individual cases of mental illness. It is intended to lead to a treatment plan. The treatment plan is intended to lead to recovery. The whole idea of it is that the mental illness ends. It’s therapy.
Alas, for some therapists and academics that is apparently too challenging. It would be nicer, they seem to feel, if the words “case conceptualization” meant something different. Something softer. Something that doesn’t require any particular clinical outcome.
In this paper we can clearly see the softening process in action. The term case conceptualization is applied to contrived exercises in which no one is mentally ill, and where there is no therapeutic alliance, no treatment and no outcome.
It is worrying that all the therapists who took part in this charade, with the exception of Joan, went along with it. It says little for the quality of their training and supervision that so many of them were complacent and compliant in the face what of was, in several essential respects, little more than a hoax.
The propaganda claims being made in this research paper are that it’s OK not to treat mental illness, and that its OK deal in generalizations about everyday life instead of in particular treatments for particular patients. Exercises of this kind encourage the idea that fantasy therapy and lifestyle CBT are a good enough substitute for the real thing.
Therapists who are serious about psychotherapy, and patients who are serious about getting well, should be very wary of approaches like this that evade the uncomfortable details of illness by retreating into navel-gazing.
