When you go to a CBT therapist for the first time, you can usully tell from your very first session how good the therapy is going to be…if you know what to look out for. By carefully evaluating your therapist after your first meeting, you can avoid wasting time and money on therapists who cannot do their job properly.
What happens next is more difficult to evaluate, but not impossible. To protect yourself from therapists who are good at the initial stages of CBT but do not know how to follow up effectively, you need to understand a little about how CBT really works.
Last year in Assess a therapist I described how you can evaluate your first CBT session. Go with an open mind, go along with whatever your therapist suggests, and try to avoid jumping to any conclusions during the session itself. Deliberately postpone your evaluation until after the session.
After the session, perhaps the next day, set aside some time to evaluate the session ruthlessly. Perhaps talk with a trusted friend about what happend, or write about it in your blog. (If you send me a link, I’ll read it and comment.) These are the questions to ask yourself:
To illustrate what can happen, here are some scenarios. I forget where I last got to in my alphabet of fictitious patients, so I’ll just jump right into the alphabet at K, and for fictitious therapists I’ll start at Z and work backwards.
Keith feels anxious most of the time, with a kind of lurking certainty in the back of his mind that something very bad is going to happen to him, except that he doesn’t know exactly what. At work he often goes into a kind of frozen state, and his colleagues think he’s depressed. But what they don’t know is that his mind is racing, going through all the possibilities of what might be just about to go wrong, and that’s why he freezes.
Keith realizes that he could benefit from psychotherapy. He books an appointment with Zara, who advertises CBT on her website and sees patients at a private health centre.
Zara starts the session by explaining what CBT is, drawing diagrams on a whiteboard. She explains that she is highly qualified, with a diploma and a Master’s degree, that she is part-way through a PhD, and that she is officially registered as a psychotherapist.
CBT, she explains, normally takes six sessions, and whether it’s successful or not depends on how much work the patient is prepared to put into it. There will be homework assignments after each session, and it is very important that Keith takes them seriously.
Then she asks Keith for some information about his previous mental health, whether he has ever been admitted to a mental hospital, been prescribed psychiatric drugs, or had any other counselling or psychotherapy. She also asks similar questions about the mental health of his parents and brother.
She ends the session by asking Keith what goals he wants to achieve by having CBT. She writes these goals down, and gives Keith a copy of the page together with a chapter photocopied from a book. Keith’s homework assignment is to read the chapter and complete the exercises.
Keith goes along with all this. Zara’s qualifications seem impressive, and she has the air of someone who knows what she is doing. He has planned to get together with his brother in the evening to evaluate his therapy session.
His brother starts with question 1, above. Zara fails.
Psychotherapy is about working with emotions. Without a strong feeling of closeness and liking, it is not possible to work with emotions. Zara is not able to achieve this closeness and liking, despite her academic qualifications and confident manner (or perhaps because of them).
Keith writes to Zara to say that regretfully he feels he must cancel his remaining appointments with her. He had gone to her because she advertised CBT, but in the first session there was no indication that she was able to create a therapeutic alliance or a CBT formulation of his problems. In addition, she gave him a photocopy of copyright material. If she bills him for the session, he has been advised to make a formal complaint to her registration body.
He never hears from her.
Yvonne’s leaflets are on the pharmacy counter at the supermarket. Keith takes one and makes an appointment. Yvonne is a counsellor and a member of the BACP. Her leaflet says she uses psychodynamic, humanistic, cognitive and bahavioural therapies to treat difficulties with emotions and relationships.
She sees patients in her front room at home. When Keith arrives, Yvonne seems genuinely pleased to see him. She makes coffee and they sit on sofas to talk. The hour seems to pass in no time. Keith feels safe and welcomed, swept up in Yvonne’s cheerfulness.
They talk about families and work, about growing up and about the future. Yvonne tells Keith a little about herself, but mostly Keith does the talking — more talking than he’s done for a long time.
There’s no homework assignment, and Yvonne explains that it’s up to Keith to decide when he feels therapy has come to an end. The important thing, she says, is for him to use their sessions together to understand himself better.
Afterwards, as he walks down the street to his car, Keith realizes that he feels oddly calm and happy. But as he gets back to the office the feeling has gone.
That evening Keith evaluates the session. On question 1, above, Yvonne did well, extraordinarily well. Most people find Keith difficult to get to know, yet Yvonne seemed to like him the moment she opened the door — not a sexual thing, just as if they were very old friends, but instantly.
On question 2, though, she failed completely. His reasons for needing psychotherapy only came up a couple of times, and the conversation drifted away each time. Keith thinks Yvonne is wrapped up in her own cheerfulness to the extent that she could probably never really understand someone like him.
Psychotherapy needs to have focus so that it does not just drift into dependency. The focus should come from a therapist’s clear understanding of what the patient’s problems are, and from a clear plan to overcome them. Yvonne does not care for this disciplined approach to therapy, so her ability to help her patients is impaired. Although some of her patients do improve over time, others just drift in and out of therapy for years.
Keith writes to Yvonne to cancel his next appointment. She didn’t do anything wrong that he can complain about, and he had a good experience to look back on. He encloses a cheque for the session.
In the next episode, Keith has an appointment with Xavier, who’s a chartered clinical psychologist and accredited CBT therapist. But can Xavier really do CBT, or does he have something else in mind?