In Part I and Part II of this series my fictitious patient, Keith, set out to find CBT therapy for his anxiety. He eventually found a therapist, Will, who passed all the tests when Keith evaluated his first session with him.
But at his second session with Will, things did not go so well. Although Will was very professional, very caring, and seemed to know exactly what he was doing, he didn’t seem to want to treat the feelings that troubled Keith the most. Instead, he only wanted to find practical ways to help Keith cope with everyday tasks.
For example, Keith had been in a meeting at work the morning before his therapy session, and there were some important things that he felt he could contribute, but his feelings of anxiety had prevented him from speaking up. He had been unable to say anything at all in the meeting. As a result his colleagues took decisions in the meeting that Keith knew would not work out well for the company.
Although Will seemed to understand this perfectly, his plan was to treat it as if Keith was simply afraid of speaking in public and worried for the company. He suggested the kind of exercises that Keith had done years ago on basic training courses for giving presentations, and he suggested that Keith should ask his boss for reassurance that the company was going to be OK.
Keith felt bewildered and frustrated. He challenged Will, asking if it was because his employer was paying for the sessions that Will only wanted to address the practical issues. Then Will, in turn, seemed confused. He tried to argue that if Keith could find solutions to all the practical problems that his anxiety was causing him, surely his anxiety would not be troublesome any more.
The session ended with the matter unresolved, and the next day Keith went back to the girl in Occupational Health to try to explain why he would not be continuing with therapy. Although she didn’t really understand, she tried her best to be sympathetic. Her mother, she said, had also had terrible problems finding a good therapist, and eventually had herself referred to an NHS hospital in another county.
Keith was taken aback. His GP had never suggested that…
What happened with Will was that he created a good therapeutic alliance with Keith in their first session, but then he got the formulation completely wrong. A therapeutic alliance is the close working relationship that you need for therapy to be effective. A formulation is a theoretical understanding of the patient’s problem that leads directly to a plan for treating it.
Will understood that Keith’s problem would start with a feeling that something bad was going to happen, and he understood that then Keith’s mind would then start to race as he tried to work out what the threat was. The result would be that Keith would seem to freeze and, for example, be unable to speak in the meeting.
But Will’s formulation was too shallow. It only took account of the end result. Although Will understood the kinds of thoughts and feelings that Keith had, he made no attempt to understand why Keith had those kinds of thoughts and feelings.
CBT aims to resolve emotional problems by applying commonsense understanding to them. To do that, the formulation (the commonsense explanation of what’s going on) has to work at three levels, answering these three questions:
Will’s formulation got question 1 wrong and didn’t attempt question 2 or 3. Will formulated that when Keith’s mind started racing, he was wrong not to speak in the meeting, and he was wrong to worry about the consequences for the company.
But the reality is that Keith felt there was terrible danger. Faced with terrible danger, Keith was correct to focus on the danger and ignore the meeting. There was nothing wrong with that thought process. And when Keith realized that his colleagues had taken bad decisions, he was correct to reason that there might be consequences for the company. There was nothing wrong with that thought process either. Will wanted to fix the parts of Keith’s thinking that were not broken, and he wanted to ignore the parts of Keith’s thinking that were broken.
To arrive at a good formulation, Will should have worked with Keith to understand that feeling of terrible danger in much more detail, to identify the processes in Keith’s mind that cause him to have that feeling, and to discover why those processes originally came into being.
Keith was correct to challenge Will and then discontinue therapy when Will showed no sign of improving his formulation.
NHS treatment varies a lot between different parts of the country. NHS patients can get a second opinion about their diagnosis from a consultant psychiatrist, or treatment from a psychotherapist, anywhere in the NHS, not limited by the place that they happen to live in.
Perhaps it is to one of those that we will find Keith travelling in the final part of this series.