Ashleigh Hennessy, 2^nd Year BA (Hons) Student, studying Counselling and Therapeutic Practice at the University of South Wales

Currently there is a lack of research and writing into the benefits of doing CBT within the pluralistic framework. Although Beck, as cited by Windy Dryden, emphasises the importance of collaboration within CBT, in practice every therapist is different and therefore each client experience may vary considerably. Although the vast majority of evidence suggests that CBT is highly effective for most client groups and most mental health disorders (see here), there are a number of people for whom this approach does not denote success. In fact, unfortunately, before I started my training to become a counsellor, I had had such a negative first experience of CBT that I ended up needing therapy to overcome my bad experience of therapy. Years later, during my first year of training, I decided to give CBT another go, in order for me to regain my belief in the approach: so that I could feel comfortable using this modality with clients. And to my surprise, this second attempt was not only useful but absolutely life changing, healing some issues I had struggled with for over 15 years. I feel that I am therefore living proof that, in terms of therapy, different people need different things at different times.

For me, the main difference between these two very different experiences I had of CBT was the collaboration and flexibility of approach used by the therapist to meet my needs. The first CBT therapist I had was so rigid in his expectations of what I was supposed to say and give him during the first session. I felt like he psychologically bulldozed me, trying to push me to tell him things I wasn’t ready to tell him, in order to help him make his initial case conceptualisation the way he wanted to. This rigid way of working quickly broke my trust and greatly contributed to the breakdown of the therapy process.

I had a completely different experience during my second experience of CBT, where I felt the therapist was much more collaborative in her way of working. I felt that she listened to me and the ways I was willing to work, thus respecting my boundaries of what I could and could not talk about, particularly in those initial few sessions while we developed the therapeutic bond. She respected my direction and pace, collaboratively working with me to adapt the CBT tools to meet my individual needs, resulting in me feeling safe enough to be able to try the various tools and techniques that CBT entails. These resulted in long lasting improvements in my symptoms after just a few sessions.

Now, in my current practice as a trainee pluralistic integrative counsellor, I regularly incorporate CBT methods alongside solution focused brief therapy and person-centred approaches, striving to provide the same collaborative flexibility of approach to my clients that my second CBT therapist gave me. So far, I have found tremendous benefit from integrating CBT tools collaboratively with clients, in line with their preferences. For instance, I have used Padesky’s 5 aspects model to help an adolescent client with their anxiety. While the CBT-based tool was designed to be used in case conceptualisation, after finding this helpful, my client asked if he could have some copies of the model to take home, so that he could use it to work on different issues throughout the week. And although this was not how the tool was rigidly designed to be used, it was more helpful for this client for me to adapt its use within his preferences and print some copies for him to take home and use independently. This was reflected in our end of therapy review a few weeks later, where he told me that this had been one of the most helpful aspects of his therapy, thus contributing to his improvement in anxiety symptoms.

For some clients, particularly those who have experienced more complex and longstanding trauma, CBT may be too direct, especially during the initial few sessions until the therapeutic bond has been sufficiently established. This is because clients who have suffered long-term complex trauma can take longer to develop trust in the therapeutic bond (see here). Collaboration and flexible adaptation of the established techniques to meet the client’s needs at the time is therefore essential. Good CBT shouldn’t be about using tools in a rigid, therapist-led way, but instead the focus should be on flexibly adapting them to meet the needs of that individual client at that particular time. In this way, we can assist clients in collaboratively designing their therapy, which could enhance therapeutic outcomes for more complex client groups, such as those with more complex PTSD which is resistant to standard CBT. CBT can be fantastically helpful for many people and the research demonstrates this, but perhaps there is a need for research into the process and outcome of a more pluralistic model of CBT, to see if this would help those who fall through the net or have additional needs.