Bertrand Russell once said that if you wear blue glasses the whole world will appear blue. The depressed look though a dark lens and may experience themselves as useless persons, living in an unpleasant world and facing a miserable future. The anxious see a world of threat in which danger is constantly in prospect, and their ability to cope is threatened by self-doubt. The obsessive are linked into a cycle of activity needed to keep themselves and others safe, although enough can never be done.
There is nothing unusual about these people. Their fears and their difficulties are shared by all of us. The difference is that in these cases the difficulties have grown so severe that they can no longer cope. They may not be able to stay employed or perform their family roles. And, if they can work, their contribution may be much reduced. No wonder that the government, in 2007, thought it worthwhile to fund a network of therapists. The economic case for helping people with a wide range of psychological issues back into the workplace made sense. The method to be used was cognitive behavioural therapy (CBT). There is hard evidence of its effectiveness with many disorders and it is relatively easy to train therapists.
In my last column I introduced CBT, noting that it retains the therapeutic force of behavioural therapies, while addressing our understanding directly. Its focus is not on the original causes of problems but on the current issues as expressed in current dysfunctional behaviour.
The underlying principle is that our emotional response to experience is not caused by the experience itself, but only by the experience as we interpret it. Supposing, for instance, that you are ignored by your hostess at a party. Various interpretations are possible: she was too busy and flustered, she had more interesting guests to talk to, she took you for granted as an old friend, you are the sort of worthless person who gets ignored. The interpretation you choose will probably tell you more about yourself than about your hostess.
Take, as a simple example, someone who feels so shy and anxious about company that he will avoid any social occasions. His therapist will explore with him the whole situation. Is there a pattern? What are the different feelings he has, and what triggers them? How does he see himself? Does he find some social occasions more comfortable than others? What bad social experiences come to mind? What would be the rewards of successful therapy?
This is not an interrogation. The form of questioning is usually “Socratic”, that is, open questions are used which provide the patient with an opportunity to explore his experiences in a liberal and accepting discussion. There are no correct answers, but the therapist, from experience and training, will be looking for certain features that are often found to accompany this disability.
From this will arise certain realisations or cognitions. These are likely to identify the negative thoughts which spring unbidden to the mind. Dysfunctional assumptions (“people recognise how useless I am”) will be explored, along with core beliefs (“I am unlovable”). From such discussions it becomes possible to formulate the deeper nature of the problem and its various aspects. While the therapist is a teacher and a guide, the results should be a mutual understanding on which a treatment plan can be agreed.
Such plans cover as wide a range as the diversity of problems, though the therapist will major on those for which there is good empirical evidence. Part of the process will be to improve recognition of half-expressed negative thoughts. A patient might be asked to note these down when they occur, for they do not survive long in the sunlight. Feelings associated with behaviour may be tracked, and their intensity and change noted. Dysfunctional assumptions can be tested, sometimes in real life. Programmes of behaviour may be agreed and monitored. Goals may be set and instruction in self-monitoring given. Ways in which patients can face their difficulties in gradual steps can be established. Deep relaxation and mindfulness meditation may be used. Progress will be measured by both therapist and patient for observing change is part of the therapy itself.
Practitioners understandably put emphasis on the measurable bases of their therapy. But I would want to emphasise the quality of the therapist himself. The healing relationship itself is important and so acceptance of the patient, depth of human understanding, ingenuity and perseverance will be needed. In the end, this is one human being endeavouring to serve another human being at a profound level. I would not hesitate to describe it as an art guided by science.
My description of CBT has been cursory but I have thought it important for us to understand, at least in outline, a major and widespread therapy which we might encounter. I think that it can teach us important things about human nature — and indeed about another channel of God’s healing work. Those who would like to study this more deeply will benefit from a clear and readable book: An Introduction to Cognitive Therapy by David Westbrook et al (Sage, £21).