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Cognitive Therapy for Challenging ProblemsReview - Cognitive Therapy for Challenging Problems
What to Do When the Basics Don't Work
by Judith S. Beck
Guilford, 2005
Review by Laura Cook
Oct 16th 2007 (Volume 11, Issue 42)

Judith Beck is a leading advocate of Cognitive Therapy, an approach which is currently widely used in both US and UK medical systems.  One of the perceived strengths of cognitive therapy is the fact that it produces relatively quick results in comparison to other more exploratory forms of 'talking therapy.'  As a solutions-focused approach, it aims to teach the individual the skills with which to deal with various problems, such as depression, anxiety, etc.  The client is assisted in identifying 'automatic thoughts' which arise when the individual is confronted with a particular situation.  These thoughts are then subjected to analysis, and supporting and contrary evidence is weighed up.  The client is assisted in seeking 'alternative explanations' which would suit the evidence.  Where the 'weighing up' process fails to work, cognitive therapy tells us that we may be in the presence of a 'core belief' – an assumption about the self which is so ingrained from early experiences that it colors and shapes every subsequent situation in which the individual finds themselves.  The next stage in the therapy is then to weigh up the evidence supporting and refuting the core belief, with a view to changing the individual's seemingly immutable view of themselves.

Cognitive Therapy for Challenging Problems is aimed at CT practitioners for whom the above methods have proved problematic or insufficient.  Beck offers a number of examples where the particular problems of the client may stand in the way of the CT technique being implemented.  She looks at clients with recognized personality disorders which automatically color their reception of both the therapist and the therapeutic process.  Beck turns her attention to each of the 'axis II disorders', such as histrionic, obsessive-compulsive, borderline and dependent personality disorders, identifying in each instance the particular facets of these disorders which will have an effect on the relationship between therapist and client.  For instance, the individual with dependent personality disorder will have a number of core beliefs, such as 'I am incompetent' or 'I need others to survive', believing in the strength and capability of others and their own relative weakness.  As a coping strategy, the individual with dependent personality disorder may display an excessive reliance upon others as defense against their own perceived weakness.  Thus decision-making and self-assertion may be difficult, if not impossible for this type of client.  Beck goes on to show how the core beliefs of 'self-weakness', 'strength of others' and their attendant coping strategies lead to 'therapy-interfering' behaviors, such as excessive compliance with the therapist.  The client may be more concerned with pleasing the therapist, rather than with seeking solutions.  Thus, Beck's book goes beyond the 'basics' insofar as it shows how challenges presented by certain clients require the therapist to consider the dynamics of the therapeutic relationship.

Importantly, Beck recognizes the therapeutic situation as a microcosm of patient's 'real-world' relationships with others.  Thus, far from being a 'neutral' zone, the consulting room can be an intensified version of how clients experience themselves as 'inferior' and duty-bound to please.  Obviously, this must be addressed if the therapy is not to become blocked.  It is encouraging to see the foregrounding of the therapeutic relationship in Beck's account, as this is an aspect often neglected in the structure of time-limited, results-orientated therapy.  Often in CT, the primary focus is on the client learning the therapeutic method, then being to apply it with confidence on their own.  The problem inherent in this approach is that it tends to suppose an entirely neutral stance to therapy, with the therapist assuming an objective, didactic role.  Recent developments in psychotherapeutic theory indicate, however, that he degree to which the therapy is successful will be down to the way in which the patient views it, not their ability to apply a method.  Implicit in CT is the notion that 'getting better' is about expanding one's knowledge-base to include better coping mechanisms.  This is reinforced by the 'homework' assignments, which focus upon the client practicing the weighing-up of evidence to examine their automatic thoughts and core beliefs.  In this respect, it is also assumed that the CT counselor has privileged skills, as they are highly experienced in this particular method.  The sense one gets when reading Beck's book is that there is an imbalance in power between therapist and client.  For instance, Beck describes the counselor as being 'objective', where it might surely be better to think of the counselor as having a different set of beliefs, which will necessarily impact upon their view of the situation.  Indeed, it would seem farcical to suggest that a therapist could, at all times, maintain a 'neutral' view of the therapeutic situation - in fact, there is evidence to suggest that this actually alienates the client.  Difficulties in the therapeutic alliance seem to be highlighted in the case studies.  The most telling example is that of 'Michael' who feels 'patronized' by the therapist.  He says to the therapist 'It's like you're the teacher or something and I'm just the student.'  (p.87) In another session, he describes a successful episode in which he was sufficiently able to challenge his negative automatic thoughts, obviously feeling upbeat.  The therapist summarizes for him what he has just said: 'You had this negative assumption, you tested it out, and you've found it wasn't true.'  (p.87) Michael then feels 'disgruntled' and patronized.  The therapist conceptualizes his belief that he is being patronized as 'dysfunctional.' It seems here that Michael's annoyance is rooted in the fact that his experiences are immediately identified as part of the CT model, and made to 'fit in' with the theory.  Indeed, on many occasions in the case studies, the 'dysfunctional' behavior seems to manifest itself as a direct result of the patient feeling themselves subject to a specified method, and thus devalued as an individual.

However, those reservations aside, this book will undoubtedly be of use to CT practitioners struggling with 'difficult' patients.  Beck's analysis of the therapeutic relationship is useful in suggesting ways in which the interpersonal relationship between therapist and client can become blocked.

© 2007 Laura Cook

Laura Cook is a research student at the University of East Anglia, and a trainee Integrative Psychotherapeutic Counselor.  Her research interests include philosophy of psychopathology, modernist literature and psychoanalysis.  She is the editor of Applying Wittgenstein by Rupert Read, forthcoming with Continuum Books.


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