Solution-Focused and Cognitive Behaviour Therapy
In this essay I would like to examine three approaches, Gestalt, Solution-focused therapy, and Cognitive Behaviour therapy and how I intend on using them within my practice as an integrative counsellor. In my previous essay I proposed how I would use the person centred, psychodynamic and existentialist approaches when working with individual client issues. I would, no doubt, be utilising the skills and techniques learned within those approaches in my practice but in this essay I would like to discuss how I would use the other three.
I subscribe to Saini’s description of the Cognitive-Behaviour approach, as a dynamic, creative structure drawing from learning theory and information processing. It seeks to combines the principles of behaviour modification and cognitive therapy while drawing on our understanding of social cognition, and our personal constructions of reality. It is further enriched by the use of techniques such as cognitive restructuring, problem solving, meditation, relaxation and stress inoculation.
As an integrative therapist, the cognitive-behavioural tradition represents an enormous resource for me. The practical and pragmatic nature of this approach means that there exists a wealth of therapeutic techniques and strategies that can be applied to different clients and their problems. Hence, I have structured my essay following the basic assembly of the Cognitive Behaviour Therapy (CBT) model but with specific techniques found within Solution Focused therapy (SFT) and Gestalt therapy.
McLeod has identified that most CBT practitioners work within a basic step by step model. I find this model useful but as an integrative practitioner, I would remain flexible with the sequence of the steps as clients are not likely to progress as systematically. I see this structure like the Transtheoretical Model of change, where change is seen as a process that unfolds over time, with progress through a series of stages, although frequently not in a linear manner.
In order for me to establish a rapport and create a working alliance with my client I am inclined to use the principles of SFT i.e. focus on the client’s strengths and resources. I would use the techniques of Problem free talk, Competency seeking and Exception finding. The client is very likely to discuss their problems and presenting issues but, I would spend time also learning about their strengths and resources. I would also look into other times when the client may have issues but managed to cope with them, there may be a pattern for coping that can be identified. Additionally, asking about exceptions to the problems, those times when the problem was not present or was being managed better is important as it will enable the client to see what made a difference to the problem and what they have the capacity to repeat.
I would also touch upon the Gestalt concept of increasing awareness with the client, going beyond intellectual awareness, and into the whole ‘organismic experienced awareness’. I would ask them to explore their emotions, physical sensations and thoughts, back then and ‘here and now’. This discussion about experiencing as a whole would then enable me introduce the cognitive – behaviour link i.e. The idea is that our thoughts, emotions, physical symptoms and behaviour can all influence one another and if not interrupted, it is self-sustaining. I would also consider introducing this concept using the hot cross bun diagram.
SFT, Gestalt and in recent years CBT, have each identified the role constructivism plays in the client’s experience of their life. As explained by O’Connell, the therapeutic encounter will enable the therapist to identify the subjectivity and cultural relativity of language the client uses to describe their realities. These personal constructs would dictate an individual’s thoughts, affect and behaviour. This is similar to irrational beliefs within CBT such as, dichotomous thinking, arbitrary inference, personalisation, over-generalisation etc.
I would choose language that will encourage change in the client as posited by SFT and Gestalt therapists. For instance using “I” statements to promote clients ownership of feelings rather than placing blame on others, using the present tense so as to focus on the present rather than the past and to encourage clients to take responsibility for their words, emotions, thoughts, and behaviours so that they recognise and accept what they are feeling (Seligman, 2006).
At this stage I would also consider training clients to detect their automatic thoughts and for this, I would consider the suggestion made by Simos, such as making notes of any obvious automatic thoughts that may emerge from the client during the session. I can then share these with the client to help them understand how the process works. I could also train the client to focus on a change in physical symptoms, like tension in the stomach or sighing as this may be a precursor or consequence of an automatic thought. I could also introduce ‘thought record sheets’ and ask the client to record their experiences and automatic thoughts. The thought records sheet would contain three sections, the (problem) situation, how it made the client feel (possibly by rating the emotion in percentages) and the thoughts the client had.
I would help the client discover and examine their automatic thoughts, their deeper beliefs, exploring both the historical origins, accuracy and/or ultimate utility of these beliefs or ideas. A way for me to do this is by using Socratic questioning to ultimately ask the client what advantages they could see by modifying their belief slightly and what they think would happen if they experimented with less rigid beliefs.
In order to set goals or targets for change, I would utilise the technique within SFT called the scaling question. The main purpose of scaling questions is to help clients set small identifiable goals, monitor their progress, start to end, and identify priorities that require action. As these goals are small improvements they are likely to be achieved within a shorter period of time which would be positively reinforcing for the client, increasing the likelihood of the client continuing to work towards making further changes. I would also follow the SMART model for setting goals. At this stage the client will also be asked to consider filling out thoughts record sheet that contain additional columns such as ‘evidence for this thinking’ and ‘alternative thought’. This is required to train the client on identifying automatic thoughts and self-correcting the dysfunctional thoughts.
During this stage I would also consider introducing relaxation exercises as well as other stress inoculations. One of these techniques is central to Gesltalt therapy i.e. being in the ‘here and now’. Clarke (2016) refers to it as ‘noticing practice’ where the client will be encouraged start noticing their body and the environment around them, how the body feels, what you can hear, smell, their breathing and if any thoughts enter their mind, acknowledge that this is what is happening and bring it back to noticing on your breathing etc. I will also ensure that I go through some relaxation exercises with the client along with some guided imagery to allow the client more positive coping tools to replace the current negative ones.
During this stage, the client is encouraged to carry out each of the key techniques that have been discussed and learned when the problem situation presents itself. The client will be asked to continue recording in the thought record sheet during this stage as it encourages the client to be aware of the choices they are making when the problem situation arises as well as the possible change in the consequences. As Rosenbaum, Hyot and Talmon identified “…any small change in a client’s life can lead to exposure to new life circumstances, which will lead to new client reactions, which will lead to new life circumstances, and so forth.
It is also necessary to monitor the client’s progress after the action stage to consider any re-assessments to be done or provide any extra training if required to facilitate the behavioural change. I will continue to use the scaling question for the ongoing assessment of target behaviours as well as collaboratively planning any further goals if required. Scaling according to O’Connell (1998) is a form of fine tuning of the therapeutic process which enables the client and the counsellor to ascertain the way in which the therapy is headed. It allows the client to stay in touch with the client’s plan for change.
Prochaska et al suggest that maintenance is the stage in which people have made concrete changes in their lifestyles and are working actively to prevent any relapses. They however, do not apply change processes as frequently as people in action. They are more confident that they can continue their changes and the positive outcomes are helping them sustain the progression of change. I would also continue using the scaling question with the client to see how close they have come to attaining their ideal solution. At this stage the client would also be seen as being able to cope and manage with new stressors, utilising their newly acquired skills.
According to Prochaska et al People in the termination stage of change no longer have the inclination to return to old habits and the new behaviour is automatic, increasing the self-efficacy percentage to 100. Personally, I find this too rigid and accept that some individuals are likely to relapse. In a study conducted by Ali et al on the durability of low intensity CBT on patients with depression and anxiety, overall, 53% of cases relapsed within 1 year. Of these relapse events, the majority (79%) occurred within the first 6 months post-treatment. I would hope that by this stage, the client has seen some positive changes to the actions that he/she has taken and understands that she has agency to actively sustain these changes.
In conclusion, as an integrative therapist I find all six approaches that I have learned are equally essential to helping clients. The first three approaches are necessary, the PCA is necessary to allow for the strong therapeutic bond to build and maintain, psychodynamic allows for the process of exploration of client problem i.e. longitudinal especially if the client is stuck within the pre-contemplative stage and Existentialism helps with exploring the breath of the problem. SFT, CBT and Gestalt are three approaches that focus on the strengths of the clients and their capacity to make changes. They also support the client acquire tools and encourages the client to utilise them to achieve the desired changes. I find that they each build from the other and for me to be effective, I would function within this framework.
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