Book Review: Cognitive Therapy: An Introduction

This is the second edition of a book that was first published in 1997. The authors asked therapists in training at that time to describe how they saw the different therapies and their therapists. The image of cognitive therapy (CT) and cognitive therapists that the trainees described was a system that was cold, intellectual, analysing, clever and unemotional.

This view echoed some of my own rather negative views, so reviewing this book has given me the opportunity to revisit and review my assumptions about cognitive therapy.

The aim in this second edition was to: 'introduce cognitive therapy, past and present, bearing in mind the criticisms as well as the huge amount of new and innovative work developing cognitive therapy as it is today' (p-xiii). Saunders and Wills have achieved that aim, not so much because of what they say, but how they express themselves. Their most important achievement for me was that they have given cognitive therapy a more human face. The authors' style of communicating was refreshingly jargon-free with a consistent non-dogmatic attitude towards cognitive theory and practice. There were sections throughout this book where I almost forgot that the authors were cognitive therapy practitioners.

The book is divided into three parts; Part One: Cognitive therapy – The Theory, Model and Structure, Part Two: Cognitive Therapy in Practice and Part Three: The Wider Context of Cognitive Therapy. The three chapters in part one were of particular interest to me:

1) The Original Model and its Recent Developments was a detailed, in depth overview of the past, present and future of cognitive therapy, showing how much this approach has changed in its 40 years of existence. Cognitive therapy has over the years evolved into something that is closer to psychotherapy with the arrival of the 'Third Wave' model that has built on, rather than replaced Beck's earlier model. Interpersonal processes, the therapeutic relationship and the integration of mindfulness have meant that cognitive therapy now tackles a broader range of problems in a more relationally attuned way.

2) Conceptualisation: the Heart of Cognitive Therapy highlighted what is possibly one of cognitive therapy's greatest strengths, which is to formulate or conceptualise a clearly articulated understanding of their system on different levels. This ability generates respect and confidence in many clients and therapists and also in a society where certainty seems to equal professionalism It is also a system of therapy that measures and assesses its treatment through rigorous and consistent research; backing up the view that this treatment works and is worth investing in.

3) The Therapeutic Relationship in Cognitive Therapy, this chapter was quite an eye opener for me. Two common criticisms of cognitive therapy are firstly that little attention is paid to the relationship between therapist and client and secondly that cognitive therapists in training are not required to have personal therapy. According to the authors this is fast becoming a myth because there is now a growing model of cognitive therapy that pays close attention to the interpersonal process of the therapeutic relationship and how this relationship can be used as an active ingredient in therapy. Paul Gilbert and Robert L. Leahy have edited a book (Gilbert and Leahy, 2007) that examines the therapeutic relationship in cognitive behavioural therapy in great detail. It now seems out dated to accuse some models of CT and CBT of not being attentive to the dynamics of the therapeutic relationship.

The authors show how the understanding and quality of the therapeutic relationship is starting to move away from a purely short-term, and business-like relationship to a collaborative relationship which involves the therapist in a much more personal way and which requires a higher level of self-awareness in the therapist. Each subheading in this chapter signals aspects of the therapeutic relationship as seen through the eyes of cognitive therapy. The subheadings that caught my attention were: Using the Therapeutic Relationship in Cognitive Therapy; Counter Transference and Cognitive Therapy; The Therapist's Role in the Relationship; Therapist's Beliefs; Personal Therapy and Cognitive Therapy and Using the Therapeutic Relationship to Produce Change.

This chapter raised my awareness how some of those who practice cognitive therapy have been willing to learn from other approaches, while, at the same time, acknowledging their own short comings. However, I found that this chapter and many of the others were full of mixed messages. An example of this was given in the description of how the Rogerian core conditions have been woven into the cognitive approach in order to build a trusting relationship thus making it easier for the therapist to challenge the client in order to 'identify and challenge the client's strange and illogical thoughts' (p.55). Who was judging these thoughts to be strange and illogical, the client, or the therapist? Of course there are thoughts that might seem strange to me but that does not necessarily make these thoughts flawed because I think they are strange. This new approach to the relationship is also informed by psychodynamic 'counter transference' and shows how useful it is for the therapist to become aware of his or her personal response to the client. In this section the authors also question the need for cognitive therapy trainees to undergo personal therapy. They challenge the widely held belief in the benefits of personal therapy for therapists in training by saying that there is 'little evidence of its overall effectiveness' (Roth and Fonagy, 1996).

I agree with their view that this might be because personal therapy is compulsory on most therapy training courses which, of course, contradicts the belief that it is important that the client decides when the time is right for therapy. Cognitive therapy's answer to personal therapy for trainees is a system that sounds like a cross between therapy and supervision, called Self Practice/Self Reflection (SP/SR). James Bennett-Levy (Levy, 2001) devised a system where the trainee undergoes cognitive therapy with a training partner. This appears to give the trainees a deeper sense of therapy and themselves and emphasises the importance of empathy, understanding, respect and tolerance. It improves their self-awareness and sharpens their understanding of cognitive therapy in practice.

Part Two: Cognitive Therapy in Practice consists of nine chapters that I found quite challenging to say the least. Chapter 5: Tools and Techniques of Cognitive Therapy: Working with Cognitive Content and Process begins by stating that cognitive therapy is characterized by methods and techniques and that the therapist comes armed with tape recorders, pens and paper, thought diaries, activity schedules and questionnaires. In summary, the overall aim of any technique is to target and modify the client's behaviour. I found myself struggling with the many diagrams, case examples, questionnaires and various thoughts, emotions and activity diary guidelines. As a client I would fall at the first hurdle in my attempt to separate and articulate my emotions, body sensations, thoughts, memories and behaviour in the form of homework, which I 'should' do before my next therapy session. All these dimensions of our experience are explored in existential therapy, but in a free-flowing and less structured way. I also wonder what the long-term effect might be of this kind of self-monitoring and how long a client could keep it up if this was not their natural way of being with themselves.

Reading these chapters made me question the relationship between therapist and client. I believe the cognitive therapist subtly sets him or herself up as an expert armed with thought diaries, activity charts and questionnaires and the one who checks the homework and drives the process with confidence. From an existential perspective this will always govern the nature of the relationship.

Chapter 8 looks at Difficulties in Cognitive Therapy and this too made interesting reading. Four common areas of difficulties are outlined as: 1) Not doing agreed homework, 2) Reacting to improvements with scepticism, 3) Showing high levels of expressed emotion to the therapist, 4) Subtly avoiding things within the session.

These are classified as 'resistance' and can be tackled in supervision in a methodical exploratory way. The four areas of resistance appeared to lead back to the original contract and agreement between therapist and client. These difficulties are then identified, assessed and conceptualised by the therapist and the client together. I was relieved to hear that the client might not always be to blame and that 'therapists must also acknowledge their own contribution to the experience, and not blame or pathologize the client'. I am not sure if this says more about the authors than the mind set of cognitive therapy generally, or perhaps I am showing my resistance by reacting to these improvements with scepticism.

The last chapter in Part two is on Ending Therapy and Preventing Relapse. Most of this chapter was common sense and could apply to many other forms of therapy. The main difference seemed to be that there is a general system that the therapist follows at the end of therapy. For example the Cognitive Therapy Blueprint, which helps the client to think about difficulties, that might happen in the future: What have I learned? - How can I build on this? - What is my plan of action? - What will make it difficult to put this plan into practice? - How will I deal with these difficulties? - What might lead to a set back? - If I do have a set back, what will I do about it?

This is a form of 'preventative medicine' and possibly a security blanket for some clients, but it is also very strategic; reminding me of 'I must do' lists where the writing of the list fulfils a need that often has very little to do with what actually happens in practice.

Paradoxically, Sanders and Wells' non-dogmatic approach left me with mixed messages at times. For example, the term 'personality disorder' is used, but here the authors admitted that they are unhappy with the term saying that if it is 'consistently misunderstood and stereotyped among professionals, the term is likely to be similarly perceived by clients'.

Part three deals with The Wider Context of Cognitive Therapy. Most of this section deals with the many strands of integration: integration of other psychotherapies, integration of experience and integration of the therapeutic relationship.

This is a well-written, engaging and thought-provoking book without a hint of putting other forms of therapy down or trying to show that cognitive therapy is superior.

I recognise that my understanding of the therapeutic relationship and therapy as a whole is very different to that described in this book. From my perspective the relationship is as personal and 'real' as any other relationship. I do not see therapy as a system where the client is encouraged to make changes in thinking, feeling or behaviour happen because changes may or may not happen. I was left feeling that cognitive therapy gave therapists and clients alike large doses of perceived certainty and fabricated structure, something we all crave. However, the elephant in the room still remains uncertainty.

Diana Mitchell

References

Bennett-Levy, J. (2001). The value of self-practice of cognitive therapy techniques and self-reflection in the training of cognitive therapists. Behavioural and Cognitive Psychotherapy, 29.

Gilbert, P. and Leahy, R.L. (ed) (2007). The Therapeutic Relationship in the Cognitive Behavioural Therapies. Hove: Routledge.

Roth, A. and Fonagy, P. (1996). What Works for Whom? A Critical Review of Psychotherapy Research. New York: Guildford Press.