’Shades of Einstein”·. (Cont’d from previous blog).

Textbooks will ‘tell’ you that it was one Aaron T Beck who originated a theory of emotion and emotional problems, by defining their core problem in depression as a “thinking disorder”. This disorder, so he explained, developed out of “negative cognitive schemas” or persistently negative and “down-beat” patterns and processes of thinking. Such negative patterns of thought were of course, underpinned by negative beliefs. From such beliefs there inevitably sprung negative interpretations, negative future predictions and thus negative feelings. Beck and others (with more than a little help from Wolpe·· mentioned earlier) then went on to impressively demonstrate – both in the treatment of depression and a host of other psychosocial and behavioural disorders – that therapeutic intervention strategies could ameliorate the disordered thinking and bring sustained improvement to the sufferer. The latter is achieved by the moderation and successful modification of these underlying dysfunctional and flawed beliefs/interpretations,

Thus Cognitive Behaviour Therapy (CBT) came into being.··· This “Here and Now therapy” (as sometimes it has been called) has quickly burgeoned into an effective and painstaking well-researched and proven treatment approach, bringing relief and sustained improvement fully into mainstream psychotherapy. It now incorporates all of the more common mental health problems, i.e. dealing with depression, anxiety and panic attacks, phobias and the like, as well as with problem relationships in their manifold forms. CBT has undoubtedly succeeded in becoming the treatment of choice for many, possessing as it undoubtedly does, negligible drawbacks and no documented adverse side-effects.

On the other hand – and as one who has for many years incorporated this popular and effective treatment strategy into regular clinical practice – it is important to warn against the belief that CBT is little more than a simple “prescriptive” (or self-applied) approach, which may readily and with little training, be successfully and consistently deployed. Indeed, it cannot and should not be viewed in that way, since any successful and durable application is likely to entail some input from a clinician/therapist possessing a full and competent range of psychotherapeutic experience·. This, among other reasons, is because CBT is not solely about changing thinking patterns: and that in turn is because thinking doesn’t take place in a vacuum. The manner, in which we think, i.e. in the present tense, requires to be set within the context of appropriate past and originating settings. For example, when we (as patient or client) describe some past occurrence or series of occurrences, e.g. such as the loss of our comfortable perception of longevity, or demotion at work or the loss of one’s job etc., the clinician/therapist will require to know and take very seriously, the patients’/clients’ evaluations/interpretations of all such events and their emotional sequelae (or consequences/conditions that result from) at that time. In other words, information of this kind requires to be carefully garnered alongside any and every factual account, since the one is likely to impinge heavily on the other. There are, of course, other reasons why skilled and experienced help is required in the successful delivery of CBT. However, the above ‘cameo’ as such, will have to suffice if one is to remain faithful to the task being attempted in this series of blogs. Sufficient is it to say that I am but one of a host of CBT practitioners who experiences a regular need to address and update one’s individually-acquired skills by attendance at teaching seminars and workshops provided by acknowledged experts in the field.

Then “why”, you might well be asking as you read on through this particular blog, “ever raise it here in the first place?” Well let me return to those sentiments, which I expressed at its very commencement and in which I commended the avoidance of negativism, in the form of sound and forward-looking logical thinking, based on the evidence available. Let me try to illustrate the kind of thing I mean from a real-life encounter. A male patient, who I was in the process of getting to know, one day said to me, “I am going to die aren’t I?” My response to his rhetorical question took the form of another question (although as I hope you will see, not in an attempt to evade the issue). “When did that thought first come to you?” I enquired. “When I was told that I had cancer”, he responded. There was another of those pauses, which I left to ‘ferment’ a little and at the end of which he added, “I feel so angry and depressed, I think with good reason. My grandfather had cancer; also an uncle on that side and my eldest brother. It killed them and that is what it is going to do to me, isn’t it”.

Now in reality (or so it has often seemed to me) we help people most, if we can deal with those fears and anxieties, which are current, albeit (as clearly his was) being ‘fuelled’ by awareness of times past. So I asked him, “How many uncles and aunts did and do you have on your dad’s side?” “Four uncles and two aunts” he replied. “And what happened to them?” I further enquired. “One died in a pit accident, another, I believe had a heart attack, one died of cancer and one’s still around. I still have an old aunt living but I think the other one died in childbirth”. “And what about brothers and sisters?” I enquired. He responded, “I’ve two brothers living and two sisters. One sister is troubled with arthritis but the other as well as my younger brother seems well enough”.

First seeking to gently apply these responses appropriately· I then asked, “Did or do other kind of accompanying thoughts, if you see what I mean, seem regularly to return to you when you think about dying?” There was a further pause, which this time I broke by adding, I hoped encouragingly, “your memory certainly seems to be in pretty ‘good nick’ anyway”. I could see that it was becoming easier for him now. “Well right at the beginning, just before I left the consultant”, my patient told me, “he put his hand on my shoulder and said, “There are certainly some things we can do but I can’t promise anything”. (Incidentally, I happened to know that the “…can’t promise anything”, was a stock in trade ‘line’ with many patients when first being interviewed by the consultant concerned). “And what did you make of that?” I asked. “Well it worried me”, he responded. “I thought; is he letting me down gently and kind of warning me…if you see what I mean? Then the next time we attended clinic, he asked my wife, “How has he been?”” “So are you saying”, I enquired, “that the “can’t promise anything” appeared to be somehow supporting the “how has he been”, or wasn’t it like that?” “No, that’s just how it was” he replied “and there were other things too…”

During the course of our discussions together, it was clearly essential to establish certain self-evident truths. The man’s disease had undeniably damaged his body and as one consequence may have limited his choices. However, he needed to see and to acknowledge that it had not impaired, for example, his capacity to choose. What required to be gently but firmly challenged was not the possibility that he might well eventually die from his cancer; that was as undeniable as were real possibilities for the containment of his disease. On the other hand, he manifestly was not going to die simply because grandfather, an uncle and a brother had met their ‘end’ in that way. Moreover and in reality, his consultants words signified nothing more than “we will do what we can” …to which he might well have added, “And there are real possibilities in this regard”. Once ‘teased’ apart in this fashion, it becomes easier to achieve a more balanced and realistic view, both of the present and the future.

The man’s self-confessed anger and depressed mood – as normal as it was predictable – also needed to be ‘teased out’ and treated as part of his need for adjustment to a cancer diagnosis (and CBT would be less likely to help in this task so much as would facilitatory counselling, which could help him explore and handle his reactions and responses). Do you see what I mean? The man’s thinking that “I might die” was a realistic negative thought and needed to be retained; but that “I might die because…my forebears died from cancer” etc. was, in this instance, a thinking error, which needed to be challenged and ‘erased’. To say, “I am ‘dead beat’ as an outcome of several weeks of radiotherapy”, is fair enough. But to conclude, “Ergo, I shall always now feel tired”, is plainly erroneous and requires to be challenged. To say, “Cancer has ruined my life”, requires a little more care in the handling. My own approach would be to first invite the patient to take one step back, i.e. to a more general question such as, “Do you think on the basis of all the evidence available to you that cancer ruins lives generally?” (Of course, this must also take into account important issues such as type of cancer, stage, prognosis, support available etc. However, even in a “worst case” scenario, for some it does, whilst for others it doesn’t).

A next question might be; “On that same basis, do you think it is true to say that cancer ruins the lives of all who contract it?” Here again (and once more bearing in mind much of what I have written immediately above) the answer should be “no”, since we can all cite people – some of them famous, others known perhaps only to us and a few friends, who in spite of everything, continue to ‘have a ball’. However, what will have been vital for all concerned (according, of course, to their own lights) is the need for adjustment given the awareness of their disease. (To be cont’d in next blog.)

  • Science is nothing more than a refinement of everyday thinking”, Albert Einstein.
  • · Wolpe’s work on “desensitization” goes right to the heart of a cognitive (thought-orientated) and behavioural approach to psychotherapy,
  • ·· It should be noted that for the “purist”, CBT has a broad historical base, drawing on the original work of Pavlov and later contributions from Wolpe,(SA) Eysenck,(UK) Skinner (USA) and others.
  • Such skilled intervention should not however be envisaged as being needed ad infinitum. Rather is its quest one of guiding the patient/client through each successive stage of the process, to the point where it is thereafter possible (and preferable) to hand over the reins of control. Indeed, the aim with every patient/client should be to impart insight into the nature of his/her difficulties, together with the provision of ‘onboard’ skills to apply them in appropriate settings.
  • There was certainly no inevitability about things since 1 in 6 members of his father’s family and 1 in 5 of his own brothers and sisters had succumbed to cancer.
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