Spring brings with it the BABCP’s Spring Workshops and Conference, whose theme this year is “Self-regulatory Approaches to CBT”. For two days next week therapists will be gathered together in London to learn about and discuss what are sometimes called ‘third wave’ approaches to treating a variety of disorders.
Conveniently for patients, the workshop programme lists the principal third-wave approaches, providing a clear warning message to patients.
Although presented as new, and with a very positive spin, third-wave approaches hark back in some ways to unsuccessful treatments of the past. Patients should be aware of some misleading aspects of these treatments before they submit to them.
The first misleading aspect is the idea that these approaches are CBT.
Cognitive Behavioural Therapy (CBT) is based on the discovery that emotions are very closely associated with thoughts and reason. In some ways this is not surprising, because we all know that emotion, thought and reason are things that ‘happen inside our heads’. CBT theory ties them all together in a very specific way that leads to practical treatments for various mental illnesses.
In simple cases CBT has been hugely successful, and this success has led CBT to overwhelm other approaches in terms of funding, training and research. But a side-effect of the success of CBT is that other approaches have been starved of funding, training and research. In order to get funding and recognition, there is a temptation for people to label their approach “CBT” when it is not.
Patients should beware that not everyone who waves a CBT flag is really practising CBT, bringing emotion, thought and reason together in a unified whole. Some therapists who wave a CBT flag do not apply CBT theory, and they might be promoting coping techniques (some of them very flaky coping techniques at that) instead of recovery techniques.
Unfortunately the organisation that should be policing this in the UK, the BABCP, colludes in the deception. If you go to the online CBT Register to find an accredited therapist, some of the registered and accredited therapists there will not treat you with CBT, but instead with some other approach that omits that specific link between emotion, thought and reason.
You might wonder why this happens if CBT has been so successful. The reason is that CBT has had two key weak spots — training, and complex illnesses.
Training to be a CBT therapist is difficult because you have to develop two very different sets of skills in parallel. You have to develop interpersonal skills, so that you can relate to patients in a very close and honest way very quickly. At the same time you have to develop skill in inductive reasoning so that you can work backwards from a patient’s thoughts and feelings to construct hypotheses about how those thoughts and feelings link together. That’s not all you have to learn, but those are the hard parts.
But if you look at how CBT courses are run, everybody passes! This is preposterous. The reality is that on completing their training, only a minority of therapists are actually capable of doing CBT.
What’s more, accreditation is mostly tied in with training courses. If you pay your money and attend the course, and you manage not to make a complete fool of yourself, you’ll end up as an accredited therapist no matter how bad you really are at doing CBT.
So a considerable amount of effort has gone into finding ways to cope with unskilled but accredited people trying to do CBT. One solution addresses lack of interpersonal skills, and another addresses lack of reasoning skills.
To address a lack of interpersonal skills, the solution is to move away from CBT as personal therapy to standardised diagnostic tools and procedures that can be administered impersonally.
To address a lack of reasoning skills, the solution is to move away from CBT as a skilled therapist making sense of a patient’s inner world, towards approaches where patients try to regulate their feelings without making any sense of them. These are the third-wave approaches.
In the area of complex illness like the personality disorders, CBT has been slow to develop as a successful treatment. Again, this is related to the skills required.
Personality disorders are disorders of relationships, so working with personality-disordered patients is extremely challenging. It exposes any weakness in the therapist’s interpersonal skills.
Equally, personality disorders can sometimes (though not always) involve more complex interactions than usual between emotion, thought and reason. So the reasoning required of a CBT therapist can also be challenging.
It is only recently that CBT methodology has been applied successfully in borderline personality disorder, the most baffling of the personality disorders. CBT’s lack of coverage in these areas has left them open to standardised and third-wave approaches.
Anger and dissociation
My first taste of third-wave approaches was long before the term was invented, in relation to anger management.
I came across a number of counsellors who had learned anger management techniques, and at the time that seemed fair enough in its way. But these counsellors applied their anger management techniques to absolutely every problem that came their way.
If a client was depressed, the depression would be relabelled as anger, and then anger management could be used. If a client was anxious, just the same. Obsessions, phobias, delusions — all would be labelled as anger and treated with anger management.
Obviously, this did not work very well. Not so obviously, it worked quite well. Many clients were willing to believe that their depression was ‘really anger’ and that their inability to control it was their own fault. People like to have a diagnosis, even if it’s daft. And people are often willing to believe that they are failures.
Many clients, therefore, were happy with the counselling that they received, because they had been diagnosed and had an explanation for their troubles, and that fact that things were no better was apparently no fault of the counsellor.
What links this to modern third-wave approaches is the underlying concept behind anger management. The concept is that someone is angry, and someone is managing the anger, but the two ‘someones’ are the same person. In this sense, anger management is a form of dissociation in which your managing (good) self is split apart from your angry (bad) self.
This sense of being split apart into good and bad selves is the unifying concept of third-wave approaches.
Illness and recovery
To understand this better, think about the difference between being mentally well and mentally ill. When you are well, there is a sense that your thoughts and feelings are integrated and reasonable. They just happen, and you accept them.
Being well is not the same as being happy. For example, you can be very depressed but still perfectly well if your thoughts explain why you are depressed and it makes sense for you to be depressed. Wellness is about emotion, thought and reason being integrated into a whole person in a way that makes sense, and that you do not generally need to think about.
Now suppose your depression becomes a depressive illness. The thing that makes it an illness is that you begin to see it as a problem. The ‘you’ who is depressed and the ‘you’ who sees it as a problem have become dissociated. There is a split between the emotional you and the reasoning you.
CBT is a way to re-integrate emotion and reason by working with thoughts. The aim of CBT is to get you back to being a whole person in whom emotion, thought and reason all work together and just happen in a way that makes sense.
Third-wave approaches, on the other hand, aim to maintain the dissociation between the (bad) ‘you’ who has troublesome emotions and the (good) ‘you’ who has the task of regulating them. If you fail in the task, it’s nobody’s fault but your own. Like that old anger management trickery, these approaches play on people’s willingness to believe daft theories and to believe in themselves as failures.
The odd one out
Here’s the list of next week’s workshops, in very brief summary. See if you can spot the odd one out:
- Dialectical Behaviour Therapy
- “an emotion focused behavioural treatment that incorporates both change and acceptance strategies”
- Self-soothing in Shame Based Difficulties
- “an emotion-regulation system, related to the ability to be self-soothing”
- Affect Regulation Training
- “this trans-diagnostic program teaches clients a set of key skills to assist them in regulating their emotions”
- Acceptance in Emotion Regulation
- “helping clients to lead ‘valued’ lives without having to necessarily remove unwanted private events”
- Assessment and Treatment of Anger
- “treatment engagement with challenging clients, cognitive restructuring and arousal reduction techniques”
Did you spot it?
They are all third-wave except the last one. The anger management workshop is the only one that’s real CBT. Engagement is about creating a close relationship with the patient, cognitive restructuring is about working with thoughts, and arousal reduction is about working with behaviour. Ironically, in these workshops at least, anger management has grown up.
Why, with all this widespread non-CBT, do I still promote the CBT Register? It’s because I think it probably contains a large proportion of therapists who can really do the job. It probably also contains quite a few who can’t, and you just have to watch out when you choose.
There are probably some counsellors, psychologists, nurses, psychiatrists, teachers, hairdressers and window cleaners who can do CBT, too, but I think they are probably quite rare. By using the register, you get a decent proportion of good choices.
Whether you are having therapy now or choosing a therapist in the future, it helps to be aware that not all forms of CBT are what they seem. In traditional CBT, recovery means becoming a whole person, just like you were before you were ill, but achieving this requires a skilled therapist. In some very different forms of therapy masquerading as CBT, recovery means accepting a permanent split in yourself while making the therapist’s job easier. You choose.