CBT Versus Client Centred Therapy
1. Levels of Client Centredness
I would like
to begin by distinguishing what I see as three levels of client centredness. The first level is the classic sense of being
client centred as outlined by Rogers. At this level the therapist strives to tune in to the client and their work
and their perspective. Their aim is to make the client feel safe and seen and received. They are striving to track and mirror
the client. They are working hard within the six core conditions as laid out by Rogers,
especially in their striving to be real with the client. In this sense the therapist is being the opposite of being technique
centred, or theory centred, or interpretation centred.
level of person centredness is the idea of choosing the correct type of therapy for the person, in other words, to determine
which type of therapy might (to borrow a medical term) be “indicated”. For instance, family therapy might seem
most appropriate in one case, behavioural therapy in another, hypnotherapy someplace else and
person centred might be indicated in a fourth instance. This approach could be useful in cases where referrals are
A third level
of person centredness is the idea as put forward by Yalom, that each time a therapist sees a new client they have to more
or less “invent” a therapeutic approach to that person that will be tailored individually to them. In this sense
the therapist moves out of the strict confines that direct practice in traditional Rogerian therapy, but also steps out of
all theoretical strait jackets, thus leaving the therapist to pick and chose from his training and his broader experience
of life and to piece together a unique therapeutic program from that. This is the eclectic approach that is sometimes spoken
of, or the “humanistic-integrative” approach. I can see myself working within the third level of person centredness.
say, the humanistic-integrative context allows for the incorporation of CBT (Cognitive Behavioural Therapy) approaches to
helping the client. For instance, I would see the usefulness of using thought experiments, actual experiments in the existential
situation, and behavioural recommendations, as part of a humanistic-integrative approach. I think this becomes apparent later
in the essay. However, I would NOT subsume non-CBT approaches under CBT premises. I would include CBT techniques with my arsenal
of therapeutic strategies. However, when it comes to embracing CBT’s central premise, that thoughts elicit feelings,
I reserve scepticism.
of economists and political philosophers, both when they are right and when they are wrong, are more powerful than is commonly
understood. Indeed, the world is ruled by little else. Practical men, who believe themselves to be quite exempt from any intellectual
influences, are usually the slaves of some defunct economist." - John Meyard Keynes
after Keynes' observation, I would not be so naive as to suggest that we should try to work within a theoretical vacuum. On
the other hand, I would counter that psychotherapy is both a science and an art, and as an art it involves some individual
judgment and creativity on the part of the practitioner. I have my own working hypotheses on how therapy can work, from my
study and my own experience with therapy. Some of this is unconscious, or at least hard to render into words that could convey
what I mean without distorting the spirit of it hopelessly. Still, this is no reason to shirk the responsibility of trying,
which is what I am undertaking to do in this essay.
works in a series of feedback loops, I believe: theory informs practice, and practice in turn refines theory. One's
practice must be based on theory (some of which is unconscious, as I already mentioned). Being a therapist is a lot about
being a human, and try putting all of that into succinct, scientifically testable premises. Being a therapist is in fact a
subset of the larger category of being a human, as is being a parent or friend or colleague or whatever.
I would venture
to suggest that the capacity of a therapist to be effective is closely indexed with his capacity to be a human being. This
is immediately paradoxical. How can a person be anything other than a human being? To take a rye look at Roger's book title,
On Becoming a Person, aren't we all already people? What can this mean? I guess there might be two senses in which a person
might be avoiding being. The first is that they might be avoiding being themselves in themselves, insofar as they are denying
or repressing their real or true self out of fear, usually.
A second sense
in which a person might not be is in the sense that they are denying something about their inevitable human condition. For
instance they might be in denial about their lack of omnipotence, the inevitability of their death, the inescapability of freedom
and responsibility for self, their sexuality, their ultimate aloneness or their vulnerability in the universe.
Denial, evasion, delusion, defence, resistance, all these can get in the way of our being. And at some level we always retain
an awareness, even at the corner of our inner vision, of our self deceit. Insofar as we are self-deceiving, we are avoiding
being. And to the degree that a therapist avoids their authentic being, to that extent they are self hampered in how far they
can go in facilitating another's growth and health.
2. A Humanistic Integrative approach to Psychotherapy: a Sketch
I will deal
with the details of this approach to psychotherapy in a separate essay, but for now I will content myself with a definition
and a brief sketch of what I mean by it. This, I hasten to point out, is an evolving conception to me.
is the provision of a safe space where the client can explore their emotional and cognitive landscape in the company of the
This is a deceptively
simple definition. It is in fact packed with significance. There are two parts to it, on first glance. Let us deal with these
“…the provision of a safe space…”
What is a “safe”
space? What are the conditions? I think Rogers was dead right
when he identified the therapist’s capacity to be real and genuine as a “core” condition for therapeutic
growth. What could feel more unsafe to a client than to suspect or fear that the therapist is being fake with them, taking
them for a ride, believing that they are a hopeless case yet carrying on with the charade for the financial reward or (worse)
the fun of it? How can the client ever know they are safe and that the therapist is on the level? How can the therapist and
the client unravel the paradox that the therapist is offering unconditional positive regard, yet the therapy is still reliant
on the client’s provision of money? And what of the paradox that is that
the therapist is trying to offer “safety” to the client, yet he himself is fallible, human, and subject to all
the flaws and imperfections that can beset the client? This is indeed the stuff of therapy.
of a “safe space” would include the following:
of commitment (insofar as is possible) on the part of the therapist to work with the client for as long as it takes to achieve
- A undertaking
not to exploit the client either physically, financially, emotionally or sexually.
of a consistent time that is reserved for the client, in a comfortable and private setting.
“…where the client can explore their emotional and cognitive landscape in the company
of the therapist”
First of all,
the bit about “in the company of the therapist” highlights the synergistic aspect of therapy. The therapist doesn’t
just track the client and try to avoid interpretation. Nor does he try to force an interpretation on to the client. In the
therapeutic relationship, the client and the therapist inevitably change one another. The work is intrinsically collaborative.
It is not merely the therapist seeking the client’s subjectivity, but rather it is unavoidable an inter-subjective dialogue
between two persons. It is something about the “in-betweenness” of the relationship and the work that brings about
change and progress that some commentators talk about (possibly Martin Buber is one of them).
space represents and recreates the world. The relationship between client and therapist offers the opportunity to explore
all the possible and actually relationships that both of them have had or that could become (come into being).
How does the
therapist help or facilitate the client is exploring their emotional and cognitive landscape?
layer is to work hard within the six core conditions for therapeutic growth as outlined by Rogers. This is not as easy as it seems. Each of the conditions is difficult to maintain
in themselves, but to add to that they can conflict with one another (for instance, congruence can conflict with unconditional
positive regard of empathy). R's six conditions include the idea of tracking and mirroring. This takes in mirroring, body
language, tone, and nuance, as well as that which the client is unaware (unconscious) of.
is working with the transference and the counter transference. This is really understanding the relationship between the client
and the therapist. This takes in boundary issues, responsibility, courage and will.
A further layer
is what my therapist calls, "analysing the defences". This takes in understanding resistance (one type of defence mechanism,
according to Freud). Intellectualisation, hysteria, illness, denial, projection, attack: these are other defensive strategies
open to the client to take refuge in. It is up to the therapist to recognise these and point these out to the client or otherwise
work with them to dispel them, to allow for authentic being to come through.
A further layer
is working-through, or what is sometimes called "cyclo-therapy". The client is in the grip of difficult emotional sets (depression,
anxiety) and beset by obsessional thoughts and feelings accompanying that. In order to discharge the emotional energy bound
up with this set, the client may need to go over the area in a series of sweeps, from a series of different angles, along
with the therapist, in order to get a handle on what its about. A large part of this is the speaking of the confusion and
the pain. It is by giving the pain and the confusion a voice that it can be finally let go of. Lacan has something to say
about this, along the lines of bringing the anxiety into the symbolic order.
along the lines that I am describing is going after a place of insight, a decisive gestalt shift, and “a-ha” moment
which offers lasting relief of symptoms. Unlike CBT, which seeks to confront distorting or unhelpful thoughts as they arise,
in a piece-meal fashion, Humanistic Integrative therapy sees thoughts as only one part of the puzzle. Other aspects include
- the relationship
between the therapist and the client, in its capacity to represent all relationships (especially formative, parental relationships)
in the client and therapists’ lives. The prospect of challenge of deep intimacy, and what that provides us with.
- the safety
of a space where the client can explore the more frightening recesses of their psyche, accompanied by a trusted and experienced
- the unconscious
(unaware) aspects of the client, that the therapist can mirror to the client.
- the existential
on-going present moment in the client’s life, involving the terror and burden of choice and responsibility.
- meaning for
the client in terms of the meaning of life.
- the struggle
to give voice and expression to hitherto unexpressed pain and emotion, the project to express the hitherto repressed.
- the gestalt
(whole view) that the therapist can arrive at from working with a client for some time, and that he can offer to the client
to consider (as Wittgenstein points out in the Tractatus, the limits of a person's world is their own perspective. The trusted
perspective of the therapist can expand our horizon).
- Various techniques
that can be used to raise the client’s awareness, which can in turn be examined by the client and therapist together
(for instance, the “empty chair” technique, taken from Gestalt therapy).
- the limits
of therapy can bring the client face to face with the limits of human life (existence) itself in the following areas: the
nature of human relationship, our essential aloneness, loss of the significant other represented by the end of therapy, the
inescapability of human fallibility, how we are condemned to be free and responsible, the difficulty of taking care, the ultimate
unknowability of the other, despite our efforts to meet one another.
- Mental distress
inevitably leads to confusion and mental hyperactivity (obsessional thinking and recycling thoughts) as the person’s
mind scrambles to grapple with the turmoil that threatens their capacity to function in the world, or even seems to threaten
their sanity. Psychotherapy offers a place where this kind of knotted functioning can be unravelled and understood and accepted,
until it finally dissolves and can be let go of.
- It seems
to me that a person suffering from mental distress needs to hold on to their illness for as long as it takes to understand
it. They hang on to it white-knuckled, like a dog hangs on to a bone. For it too important to let go of, since it poses
such an internal threat to the safety of the person themselves (it could lead to destitution, incarceration or could
be ultimately lethal, in that it could lead eventually to suicide). There is a tremendous need to understand, to know
(almost like a "will no know") in the person, seeking desperately to grasp the nature of the problem, so as to disarm
and eventually let go of it, knowing that it is neutralised permanently, thus becoming free to get on with living.
political struggle and religious undertakings can be very cathartic endeavours in that they grapple with the fundamentals
of life and they give a constructive location into which a person can channel their energies. In this sense therapy is a bit
like artistic creation, in that by giving a pain expression it is transcended and grasped, and therefore safely let go, liberating
the client to move on.
A core assumption
of humanistic Integrative psychotherapy is that each person has the seed of their own growth and integration within themselves,
and that it is the therapist’s role to assist the client in clearing away such blockages as have arisen that are blocking
the client’s progress to becoming themselves (i.e. becoming fully human, becoming more aware, feeling free and unafraid
to be and express their deep and genuine organic urges and aspirations, and leading a full (in whatever sense they feel is
full) and self-responsible life).
After Thought: A second definition:
is about the attempt at creating an inter-subjective shared space, where the therapist works to bring into existence a
safe environment, to facilitate the joint exploration of both person's existential and ontological experience, as being
persons in the world, persons among other people, beings with freedom and responsibility, and beings ultimately
facing the reality of death".
might seem a bit too heavy for some perhaps. That's why its a second definition.
3. Reservations about CBT
CBT is based
on the premise that thoughts elicit emotions. As you think, so you shall feel, could be the CBT motto. I accept Beck’s
observations on parallel thought processes and automatic thoughts. I accept Beck’s “experiment” intervention
as being useful, i.e. by doing experiments to disprove them we can learn new kinds of competencies and develop our courage
and our will. For instance, a client is assuming they know the thoughts and opinions of another person. The therapist suggests
that the client “checks it out” with the other person, that is, ask the other person what they actually think
and believe. This can help counteract “mind-reading” This takes in both thought experiments and experiments in
the client’s existential behaviour. To complement this, Kelly argues that each person can be thought of as a scientist,
posing hypotheses, testing these hypotheses with experiments (both thought experiments and ones in the field). The therapist
using CBT in this sense could be seen to be honing the scientific approach of the client he is working with.
I accept that
behavioural therapy that says, change his behaviour and you change how he feels has a good track record of results. It is
so different from all the various flavours of the "talking cure" (and cognitive therapy as part of that spectrum), that perhaps
it should best be spoken of separately from cognitive therapy. The "C" and the "B" of CBT are quite distinct strands
of practice within a therapeutic school of thought. Yet historically they are lumped in together as C-B-T. So be
“change how he thinks and you change how he feels”, is the part I have most difficulty with. In a sense the premise
is valid enough, since it is so broad. All strands of the post-Freudian talking cure seek to change the client's thoughts
and feelings. It just begs the question, how do I change how he thinks and feels? According to CBT the therapist shows
the client how their logic is faulty and teaches them to check their own faulty reasoning regularly. In a sense the therapist
is teaching the client a skill: the skill of challenging themselves, their thinking and their assumptions.
I have with this is basically twofold. Firstly, we all know when we are being irrational. Knowing that we are being irrational
is about as useful as telling a person who has already begun falling off a cliff that they are falling off a cliff: they're
already on the way down. What they want to know is not whether the thoughts are rational (they already know they are
not), but rather where do they come from and most crucially, why. Secondly, I would tend to favour the premise that thoughts
are the surface manifestation of our feelings (the contrast of thoughts and feelings is a big topic onto itself, and can only
be touched on here), and that our feelings come from deep inside us (literally, from the lower, more ancient parts of our
brain, the limbic system). If (1) our sense of self, (2) our feelings, or (3) the connection between our feelings (all of
them, especially the difficult ones like anger and fear) and our thoughts is damaged, then this will continue to generate
the problematic thoughts that CBT strives to counteract.
I think I am
following Antonio Damasio (author of The Feeling of What Happens) and David Hume in regard to viewing reason as the slave
to the passions, giving them shape and direction. Of course reason informs and educates the passions in turn. However, part
of the task of educating the passions must involve understanding them in their own terms too. If one insists on viewing certain
cognitions as simply dysfunctional and "irrational", and only fit to be refuted and denied, they will never be understood.
They are simply distorted. This could be a replaying of the parental home and the school yard, where certain feelings were
denied to the person as a child. This denial and process of bastardisation of those thoughts and feelings becomes internalised,
and the CBT therapist now joins the adult ego of the client in beating these difficult, disintegrated parts of the self down.
These difficult elements (which remain infantile since they have never been allowed the chance to be exposed to "growing up")
remain misunderstood, marginalised and denied expression or integration. They don't go away. They demand to be heard. They
are usually bound up with a very hurt aspect of the person (the part that was distorted by their environment because it couldn't
or wouldn't handle their real, authentic self) and this part is naturally seeking to be healed. It will always remain
a latent threat as long as it is not integrated, and the ego knows this. Plus it is a useful part, that can have its usefulness
released for use if only it could be brought within the sphere of awareness and acceptance. But bringing it out involves a
lot of fear of rejection and loss of control to the distrusted aspects of the self. Hence the importance of safety and security
and time as part of the therapeutic relationship.
To use an analogy,
the human heart-mind could be compared to a concrete yard. The concrete represents the barrier, the defence mechanisms, between
the conscious (above ground) and the unconscious (beneath the concrete). The weeds that grow through the cracks are the difficult
thoughts. CBT tries to pull up the weeds as soon as they appear. But the cracks remain and so does the soil beneath, so the
weeds keep coming through, naturally. Under pressure more cracks will appear and more weeds – just as for a person under
pressure will see their negative thoughts multiply and grow louder in volume in calling for attention to their needs. If you
really want to block the weeds (and avoid harmful chemical spray: anti-depressants and tranquilisers) you need to tackle the
problem at source: where the weeds are coming from, what is going on beneath the concrete. At the deeper levels of the self
there are unconscious dynamics that need insight to be resolved.
How can this
be done? I would say that in contrast to the CBT approach, it is through a basically person-centred approach, already outlined,
that the person can be lead in this kind of deep, insight-based work. As Freud himself once recognised, it is when the client
comes to a realisation (interpretation) themselves that they most embrace it. The therapist can help to client to find the
insight, but he cannot “give” it to him. It is a replay of the old adage, “you can take a horse to water,
but you cannot make him drink”.