Running head: COGNITVE-BEHAVIOR THERAPY
The Use of Cognitive Therapy and Existential Therapy from a Theoretical Integration Perspective
Daniela Plaiasu
University of Calgary
CAAP 601
Table of Contents
A) Introduction 3
B) Philosophical Assumption 3
Nature of humans 4
Healthy Functioning 9 Major causes of problems 10
Nature of change 11
C) Counselling Experience 13
Definition of counselling 13
Counselling process beliefs:
Counsellor-client relationship 14
Roles of client and counsellor 15
Session length, duration and number 16
Emphasis on the past, present, future 16
Emphasis on beliefs, emotions and behaviours 17
Change process including resistance 18
Interventions 19
Success 21
Contextual factors 21
Reflection: Weaknesses of own personal theory 22
Closing: Concluding remarks 22
References 23
Theoretical Integration
The Nature of Theory posits that a “good theory” is comprehensive yet parsimonious, operationally accessible, easily generalized across a diverse population, and has heuristic and applied value (Magnusson, 2006, The Nature of Theory). The goal of this paper is to outline my stand on the theoretical frameworks that make sense to me at this point in my professional development. In the subsequent sections, I will describe how Cognitive Therapy (CT) and Existential Therapy (ET) principles can be utilized while working from a theoretical integrative systems model. Next, I will integrate the ET and CT into a cohesive personal theory that represents my personal way of understanding and describing human behaviour and client change.
Philosophical Assumptions
The clientele I work with is made up of a mosaic of different cultures, language, gender, age range, education, social and economic upbringing. Their needs are multifaceted and as such, they need to be approached accordingly. For example, there have been instances when their problems were exacerbated not only by severe hardship such as war, torture, or unsatisfactory nutrition, inadequate shelter and health, but also by alienation, isolation and mild to moderate addictions. Most addicts require two stages of treatment for successful recovery. Stage one requires the client’s commitment to controlled, structured, directive approach and stage two involves the personal change or growth the client makes after breaking the addictions.
Yalom (1989) has pointed out that theories of psychotherapy are developed to reduce the counselor’s anxiety in dealing with the complexities and the uncertainties of the therapeutic process. In saying this, I realized that a theoretical integrative approach would give me the freedom to embrace an attitude towards my clients that would affirm the inherent value of each of them. Corey (2009) posits that integrative therapy is a synthesis of the diverse theoretical orientations, concepts and techniques that fit the uniqueness of a therapist’s personality and style. Arkowitz, (1997) states that an integrative approach is characterized by attempts to look beyond and across the confines of single-school approaches in order to see what can be learned from and how clients can benefit from other perspectives. Preston (1998) states that a single theoretical model cannot adequately address the wide range of problems clients present in therapy and that is essential for therapists to have a basic grasp of various therapeutic models and a number of intervention strategies their disposal.
There are a number of commonly accepted modes of forms of psychotherapy integration in which theory and techniques have been integrated. My long-term goal is to use theoretical integration where two or more therapies in order to create a conceptual framework that will synthesize elements of two or more therapies. This not only will provide me with a good theoretical foundation to expand my understanding and use of other therapy modalities, but also with a good understanding of my clients’ various needs. Bugental & Sterling Gurman (1995) posit that integrative therapy is the “willingness to learn from all therapies and therapists, rather than to declare exclusive loyalty to one school or model of psychotherapy (p. 317) “. Corey (2009) agrees and states, “no single theory is comprehensive enough to account for the complexities of human behavior, especially when the range of client types and their specific problems are taken into consideration” (p.450).
Nature of Humans
IT emphasizes the process of change without adhering to a specific theory of personality. Narcross & Beutler (2011) state “IT is relatively personality-lesss and immediately change-full (p. 511)”. They posit that the IT is mainly concern with tailoring therapies to suit clients’ personality. Even though the IT does not “rely on a theory of personality is not to say that it pays no heed to personality characteristics” and that “the patient’s personality is a key determinant in the IT” ( Narcross & Beutler, 2011, p. 511).
Narcross & Beutler (2011) posit that there are five client characteristics broadly used the IT therapists to determine a match between client and treatment. These five characteristics are diagnosis, stages of change, coping style, reactance level and patient preferences. The IT does not rely entirely on the diagnosis because it disregards a client’s strengths and therefore is not sufficient for treatment planning. Besides, the criteria for disorders are various, change repeatedly and opt for different categories of clients. Adis, Wade, & Hatgis (1999) showed that diagnosis manuals negatively influenced the quality of the therapeutic relationship, unnecessarily and inadvertently curtailed the scope of treatment, and decreased likelihood of clinical innovation. The IT is using assessments to collect information on clients’ presenting problems, relevant histories, treatment expectations and goals and building relationships.
According to Narcross & Beutler (2011), there are five stages of client change: precontemplation, contemplation, preparation, action and maintenance. The precontemplation represents the stage when clients do not want to change their behaviour in the near future because they do not want to recognize that they have problem. The hallmark of this stage is their resistance to recognize their problems. Contemplation is the next stage and as the stage when clients are aware of their problems and they talk about how to overcome them, but yet there is not commitment. The characteristic of this stage is problem resolution. The third stage is preparation, which combines intervention and behavioural criteria. Clients intend to take action in the future, but they take unsuccessful action in the present. The next stage is the action that is characterized by clients modifying their behavior, experiences and/or environment in order to conquer their problems. The last stage is the maintenance when clients are working on prevent relapse.
Copying style is the next characteristic and represents the habitual behaviour of the clients when confronting novel and problematic encounters. Clients who are impulsive, extroverted and simulation-seeking are externalizing their coping whereas clients who are self-critical, inhibited and extroverted are internalizing their coping. The next client’s characteristic is the resistance level as in called resistance. The level of resistance directs the type of interventions. For example, high reactance clients directs for nondirective, self-directed, or paradoxical approach while low reactance clients direct for a directive approach (Narcross & Beutler, 2011).
The last of the client’s characteristics is client preferences. An example of clients’ preference for different types of therapies is offered by the study of Glass, Arnkoff, and Shapiro (2001). After reviewing a number of studies of the effect on out come of accommodating client preferences, Glass, Arnkoff, and Shapiro concluded that “clients who receive a treatment they believe in and prefer may be more likely to engage early in therapy, work hard, and comply with and continue in treatment, leading to better outcome (p. 240)”. Another study by Van Audenhove and Vertommen (2000) found that clients who were educated and informed about their therapeutic options, and then allowed to choose their types of therapy and their particular therapists, had lower dropout rates from therapy than other clients. Wanigaratne & Barker (1995) also studied clients’ preference for different type of therapy. Clients had to watch videos depicting psychodynamic, cognitive-behavioural, humanistic, and external and naive therapy. After seeing each video, clients rated credibility, personal preference, and the depth and smoothness subscales of the Session Evaluation Questionnaire. Credibility and personal preference were highly correlated. Overall, clients had clear differential preferences between styles and the cognitive-behavioural style was preferred to other styles in all measures. Hence, these preferences may be influenced by the client’s socio-demographics such as gender, ethnicity, culture and social orientation and may be related to gender, age, religion, race of the therapist, to the therapeutic relationship, to the therapy method or the treatment format (Narcross & Beutler, 2011).
For the purpose of this assignment, I will combine cognitive therapy with existential therapy. Corey (2009) asserts that humans are self-aware and that therefore they need to accept the responsibility that comes with being free and understand themselves in relation to knowing and interacting with others while striving to protect their individual identity. The meaning of our lives is not static and is derived by the meanings that we create ourselves through what we do in life and that anxiety and death are part of being human.
CT posits that humans like other organisms, have mechanisms in place to help process select information from the external environment to ensure survival. CT views personality as a reflection of the individual’s cognitive organisation and structure, which is influenced by our biology and the environment (Beck & Weishaar, 2011). CT postulates that such human responses are developed through our long history of learning and evolution and that thinking is important to our survival (Beck & Weishaar, 2011; Mash, 2006).
The bases of personality development are the interactions between a person’s innate characterises and their environment (Beck & Weishaar, 2011). One’s personality can be witnessed through the schemas they hold of the world, as well as the strategies they choose in reaction to different situations. Psychopathology stems from the result of a number of influences such as individual learning, inadequate responses to the environment or misinterpretations of the environment, and their biological makeup.
CT draws attention to the role of early experience on current cognition and behaviour and the shaping of the personality (Mosak & Maniacci, 2011). According to CT, clients’ behaviour and feelings are a result of their inner dialogue and if cognitions change, the behaviour and feelings of the clients will change, too. Maladaptive thought arise because of faulty thinking, inaccurate interpretations of situations and events, and the inability to differentiate reality from fantasy.
CT also draws attention to the role of early experience on current cognition and behaviour and the shaping of the personality via innate and environmental factor and holds that individuals form core beliefs based on their own interpretations of life experiences (Mosak & Maniacci, 2011). Beck & Weishaar, (2011) stipulate that “personality attributes are seen as reflecting basic schemas, or interpersonal strategies, developed in response to the environment” (p. 284).
The ET stipulates that all persons have the capacity for self-awareness and in saying that, they must accept the responsibility that comes with this freedom. Each person must continually recreate himself/herself as the meaning of life and existence is never fixed. Anxiety is part of the human condition and death is a basic human condition that gives significance to life (Yalom & Josselon, 2011). I see my clients as complicated being and I believe that their culture, race, and society are important considerations when I attempt to understand them during the therapeutic process.
Yalom and Josselson (2011), affirm that existential therapists consider, accept, and address the uniqueness of individuals including the influence of age, sexual orientation, and ethnicity. I pay attention to my clients’ immediate experience in order to help them create greater meaning in their life rather than providing them with solutions to their problems. The goal of therapy is to help clients see how they are not living fully authentic lives and to make choices in their lives that will ensure that they reach their full potential (Corey, 2009
Healthy Functioning
According to Bugenta & Sterling (1995), “most integrative therapies contain within them the definition and conceptualization of health and pathology that derive from the specific component therapies that are amalgamated” ( p.323). They posit that integrationists characterize the healthy functioning of people as defined by their ability to define, develop plans, modify and adapt them, learn from self-generated and other-generated feedback, and attain to their goals without interpersonal or intrapersonal interference (Bugenta & Sterling, 1995).
IT works from a developmental framework in which the role of the early life events such as childhood and adolescence are essential in the development of perception, thinking and motivation (Wachtel, 1997). According to Bugental, & Sterling (1995), when “ negative, painful, anxious, and defeated familial and social interactions are internalized and become part of the patient’s cognitive and emotional representational system”, they can “ lead the patient into avoidant, defensive, and ultimately self-defeating and self-replicating patterns of construing reality and of social relatedness” (p. 324).
People hold beliefs about others and the world around them that may lead to biased interpretation of certain situations that can lead to distorted thinking (Mash, 2006). Corey (2009) posits that emotional disturbances “stem from faulty thinking, making incorrect inferences on the basis of inadequate or incorrect information, failing to distinguish between fantasy and reality and negative automatic thoughts” ( p. 143). Beck & Weishaar (2011) state that “thoughts mediate between stimuli, such as external events, and emotions” and that they “elicit a thought that in turn gives rise to a negative of positive emotion” (p. 284). Beck (1997) contends that clients’ health functioning is put in jeopardy when they label and evaluate themselves by a set of rules that are unrealistic.
ET states that healthy functioning directly correlates to the concept of freedom and responsibility. The concern of freedom relates to one’s responsibility over their life while the concept of responsibility refers to the clients’ ability to take ownership over their life and take responsibility for their own life decisions. The role of the therapists will be to aide clients to take responsibility over their life, to point out thinking patterns that are causing problems and times when the client avoids taking responsibility (Yalom & Josselson, 2011).
ET encourages clients to address the emotional issues they face through full engagement and responsibility for the decisions that caused them to develop. I guide clients to accept their fears and overcome them through action. By gaining control of the direction of their life, clients are able to design the course of their choosing. This creates in my clients a sense of liberation and a feeling of letting go of the despair that is associated with insignificance and meaningless (Yalom & Josselson, 2011).
Major Causes of Problems
According to Shedler & Block (1990), “cognitive distortions refer to misinterpretations of reality that reinforce negative conclusions regarding the self, world, or future (p. 147). Mash (2006) states that distorted thought patterns, including problems in thought content and process, can lead to psychological problems. Cognitive distortions and attributional biases have been identified is studies of depression, aggression, ADHD, and anxiety (Mash 2006).
Each person has a unique identity that can come to be known only through relationships with others. For different reasons, my clients lack closeness with others around them and struggle to make meaningful connections to other people. The feeling of isolation causes so much anxiety that defence mechanisms are easily built against it (Yalom & Josselson, 2011). When clients make connections, their anxiety diminishes. ET posits that an awareness of death can create new outlooks on life and can create personal change (Yalom & Josselson, 2011). I am helping clients to see death as an awakening experience and manage the anxiety around it in a proper way so that they can have fully authentic lives.
Nature of Change
Corsini (2011) states that change is the result of interrelated processes such as the therapeutic relationship, treatments used, and the client’s willpower to avoid relapse.
Cognitive therapy is built on the idea that cognitions are the root of people’s actions and feelings (Corey, 2009). According to the CT, a client’s behaviour and feelings are a result of their inner dialogue. The underlying premise is that if cognitions change, behaviour and feelings will also change. Problems arise as a result of faulty thinking, inaccurate interpretations of situations, and an inability to effectively differentiate reality from fantasy. The goal of the therapy is to change the client’s problematic behaviour and emotions by changing their dysfunctional way of thinking (Corey, 2009; Pledge, 2004; Yalom & Josselson, 2011).
I believe CT is an effective modality to utilize when helping clients changes their interactional pattern. Therapists utilize experiments to test maladaptive assumptions and foster new ways of thinking. Behavioural techniques are also used to help the client learn new responses to particular situations, help them to relax or stimulate them, or in preparation for fearful situations (Beck & Weishaar, 2011). Some of the behavioural techniques I use with my clients include: homework assignments; hypothesis testing; exposure therapy; behavioural rehearsal and role playing; diversion strategies; activity scheduling; and graded-task assignments (Beck & Weishaar, 2011).
CT and ET are workable therapies when working with a large spectrum of clientele who are either in their final stage of therapy or drawn to working with this integrative approach. I believe CT is an effective therapeutic approach to couple with ET because the first offers a structured, directive, and problem oriented approach while the second offers a non-directive approach. The two theories can be applied to a large variety of clientele as they are matching the needs of high and low resistant clients.
Although cognitive therapy can be more directive than existential therapy, the two are similar in that they attempt to help clients by encouraging them to utilize the information and facts to form new perspectives. Besides, both therapies avoid providing clients with solutions to their problems and help produce change by guiding them toward their own solutions. Furthermore, the two therapies require a strong and collaborative therapeutic relationship and help individuals discover new ways of thinking for themselves.
ET does not provide a lot of guidance to the therapist regarding how to change the client’s behaviour, but it does provide a clear rationale of what is causing the problems and what needs to be changed. A client is caused anxiety by inner conflict in relation to the ultimate existential concerns that we all struggle with (Yalom & Josselson, 2011). According to ET, anxiety can be used to help the client move toward their goals and is a necessary part of life. The goal of the therapist is to help the client discover barriers in their life and to take responsibility for their actions rather than providing the client with solutions to their problems (Yalom & Josselson, 2011). Rather than providing direct solutions to the client, the therapist focuses on building a strong relationship with the client based on empathy.
The Counselling Experience
Personal Definition of Counselling
I define counselling as a special relationship between a person in need on psychological services and a trained professional. The relationship is special because the counsellor tries to create an atmosphere in which the distresses individual feels comfortable expressing important and often confident information. In counselling clients are viewed as normally, functioning individuals who need help developing their potential. The experience of counselling is different for each individual and brings about changes in their behaviour, feeling, and thinking. Counselling is likely more successful when the individual identifies their own problem and develops solutions of how to overcome it. Counselling is the facilitation of that conversation whereby the counsellor guides the individual toward self-discovery of problems and solutions.
I believe people change when motivated to do so. I believe that people may need some guidance regarding why they may need to make some changes in their lives and what those changes may mean for their future. People who are motivated to change may not always know how to make the change they desire; therefore, counselling can help them develop their own strategies for change and/or suggest strategies that could be useful. Well-timed questions of the individual/group regarding the problems, desires, and possible strategies to achieve change can also be effective.
Studying theories of counselling and change is very important because it adds to my repertoire of strategies to help people make changes. People vary in many different ways including how they make changes in their lives; therefore, certain people will respond more positively to different techniques than others. Having an understanding of more than one theory will enhance my ability to be creative and effective when working with diverse populations. I believe that ongoing education of therapeutic theories and best-practices is an essential part of my personal theory of counselling.
The Counselling Experience
Counsellor-client relationship. The working alliance takes into consideration the therapist’s role, the client’s role and the relationship between them which is crucial to the therapeutic outcome (Shedler & Block, 1990, p. 48). Both, CT and ET posit that the relationship between client and therapist is important and change is best realized when the relationship is collaborative (Goldenberg et al., 2011; Mash, 2006).
The development of a strong collaborative therapeutic relationship is important to the application of therapeutic techniques (Lejuez, Hopko, Levine, Gholkar, & Collins, 2006). CT is seen as a collaborative process whereby therapist and client work together in identifying dysfunctional thinking and testing assumptions (Corey, 2009). Known as collaborative empiricism, the therapist and client work together to investigate problems, develop hypotheses, set goals, and challenge assumptions in hopes of changing the client’s behaviour. For example, I remark that my clients are more likely to respond to my suggestions and advice and do their homework assignments when they trust me (Mash, 2006).
A trusting therapeutic relationship is also important when identifying goals (Mash, 2006). The primary goal of CT is the reorganization of the old schemas and the creation of new schemas. Hence, I am sensitive to relationship issues as I am working towards building a trusting relationship with my clients early in the therapy. After identifying problems, it is important to work collaboratively with my clients on setting up goals to deal with their problems (Somers & Queree, 2007). Goodheart, Kazdin & Sternberg (2006) affirm that when there is agreement on goals and tasks, the working alliance is related to better outcomes.
Corsini (2011) postulates that the “heart of the therapy is a caring, deeply human meeting between two people” who are both “exposed to the same existential issues of meaning, isolation, freedom , and death (p. 332)”. Genuiness is crucial to an effective ET because “we all face the terror, the wound of mortality, the worm of the core existence” and in order to be “truly present with patients dealing with death anxiety, the therapist need to be open to his or her own death anxiety ( Corsini, 2011, p. 332) “. ET sees the therapeutic relationship as key to healing with the focus on the intimacy and genuineness of the counsellor and client interaction (Yalom & Josselson, 2011). Transparency is another important element of the therapeutic relationship because “always facilitates therapy” (Corsini, 2011, p. 332). Corsini (2011) states that empathy is the most powerful tool we have to connect with other people and according to him, it is “the glue of human connectedness” that “permits one to feel, at a deeper level, what someone else is feeling” (p. 330).
Roles of the clients and counsellor. In both therapies, clients are encouraged to be active participants in the therapeutic process as the therapy is thought to be a highly interactive process between therapist and client. In the CT, the therapist acts as a guide, co-investigator, catalyst, educator and role model. The therapist takes an active role in assessing the situation, evaluates what thoughts, beliefs, and behaviors are contributing to the problem and make recommendations about how to precede with changing them. The role of the therapist is to identify what skills are needed and to provide active skills whereas the role of the client is to learn new skills by completing the assigned homework. Beck stipulates that the therapeutic stance is genuine, empathetic and flexible, while at the same time, action-oriented and at times directive (Beck & Weishaar, 2011).
In the ET, the therapist and client are both involved in a journey of self-discovery. The counsellor position of fellow traveler is described as two people sharing the same existential concerns and ultimately the same fate. According to Yalom & Josselson, (2011), “existential therapists begin with the presuppositions about the sources of a patient’s anguish and view the patient in human rather than behavioral or mechanistic terms” (p. 322). The existential therapists strives for an understanding of the client’s current situation and their unconscious fear and they do not help clients to uncover their past.
Session length, duration, and number. The goal of CT is to correct faulty thinking and to help patients modify assumptions that maintain maladaptive behaviours and emotions (Beck & Weishaar, 2011). According to Corsini (2011), CT sessions are usually 45 minutes to one hour. The therapy is conducted in a structured and time-limited manner and the number of sessions can vary from 10 to 20. Most patients meet with their therapist on a weekly basis. Typically, the therapy begins with building a collaborative therapeutic relationship with the client and the sessions focus on current concrete and specific problems.
The ET is interested in helping clients to find philosophical meaning in the face of anxiety by choosing to think and act authentically and responsibly. ET does not provide a lot of guidance to the therapist in regarding to how to change a client’s behaviour, but it does provide a clear rationale of what is causing their problems and what needs to be changed. The ET can be short or long-term depending on the issues that client and therapist need to cover and usually last at least for several months.
Emphasis on the past, present and future. CT remains focused predominantly on what individuals are feeling and on how they are coping in the present (Goldenberg et al., 2011; Somers & Queree, 2007). Past experiences are not entirely overlooked, but rather explored to the extent that they can provide insight into why the client thought certain behaviours or through patterns were useful. Current thought patterns are recognized as being no longer appropriate or functional and alternative thoughts are sought.
The two theories focus on the present and emphasis the well-being of the individual. ET is interested in the choices that clients are currently making and the shift from past challenges to present awareness. According to the existential theory, individuals are responsible for making meaning out of their life and anxiety arises when they exercise improper judgment.
Emphasis on beliefs, emotions, and behaviours. CT interventions focus on cognitive, affective, and behavioural processes (Mash, 2006). According to Mash, psychological disturbances are the result of faulty though patterns including erroneous beliefs, irregular thinking, and poor problem solving. The goal of CT is to identify maladaptive thought patterns and replace them with more adaptive ones (Mash, 2006).
Cognitive therapists also emphasize emotional factors such as affect (Beck & Weishaar, 2011). CT has developed interventions for disturbances that are affective in nature including depression and anxiety symptoms (Mash, 2006). According to Mash, cognitive therapists are concerned with emotional processes such as arousal and the influence over other types of behaviour including aggression. Cognitive models posit that individuals’ emotional state affects social-cognitive processes such as attributions of causality (Laible & Thompson, 2007; Mash).
CT aligns with ET regarding the importance of adaptive cognition, affect and behavior. Both, CT and ET acknowledge the importance of genetic, physiological and social factors on psychopathology. Existential therapists work with clients on a clarifying the meaning of life and the management of anxiety. For example, Frankl (1973) states that depression is the "tension between what the person is and what he ought to be." (p. 202). When clients cannot reach their goals, they lose of sense of their own future. Over time, they become repulsed at themselves and project that onto other people or even humanity in general (Frankl, 1973, p. 202).
Change process. CT outlines a direction for the process of therapy beginning with the goal of the first session and outlining the focus for subsequent sessions (Beck & Weishaar, 2011). Cognitive therapists help individuals realize change by creating a comprehensive case formulation in collaboration with them. Case formulation is a model of the problems and factors that may be contributing to the problems (Somers & Queree, 2007). Such a model can be created through the use of journals or records that the client keeps. For example, I ask my clients to keep track of how many times they have a certain belief or act in a certain way. They need to log their feelings associated with the belief, the evidence for the belief, and possible alternative evidence in support of different conclusions (Mash, 2006). I use the logs to help them make connections between these elements and help them understand what causes the problem/s (Somers & Queree). The case formulations are often comprehensive and evolving. For example, if new information is presented through the course of therapy, then the case formulation will be adjusted to meet the needs of the client.
I utilize verbal techniques to identify my clients’ thought patterns, analyze the logic of the thoughts, and highlight the irrational thoughts (Beck & Weishaar, 2011; Mash, 2006). For example, I ask my clients questions pertaining to situations where they felt upset and once they are willing to identify their thinking at the time, we then work together on identifying the dysfunctional thinking. I do not interpret my client’s thoughts, but rather explore the meaning of those thoughts with them (Corey, 2009; Mash & Wolfe, 2005). Past issues may be uncovered, but only to provide me with further information that might be helpful in identifying behavioural patterns or faulty cognitions that need to be changed.
ET assumes that a central problem that people face are embedded in anxiety over loneliness, isolation, despair, and, ultimately, death. Existential therapists believe that anxiety is caused by inner conflict in relation to the ultimate existential concerns that we all must struggle with (Yalom & Josselson, 2011). This conflict is a result of an imbalance between how clients live their life and their unconscious needs. Clients use defence mechanisms to avoid this anxiety, but instead this leads them to conflict and the inability for them to lead a fully authentic life.
The goal of the therapy is to help my clients discover barriers in their life and take responsibility for their actions rather than providing them with solutions to their problems (Yalom & Josselson, 2011. I encourage them to take responsibility of their life and I point out times when they avoid doing that (Yalom & Josselson, 2011). The next step is to help them develop meaning in their life and help them to establish things that are rewarding in their life.
Interventions. CT clearly outlines a direction for the process of therapy beginning with the goal of the first session, then outlining the focus for subsequent sessions, as well as lending a prescription for ending treatment. My clients are coming into the program during the action stage of the integrative therapy when they are ready to work on their problems. I aid them to realize that their negative thoughts (schemas) can be the results of their false perception and interpretation of the reality. We work together on identifying automatic thoughs and learn how to find new thought alternatives that reflect reality more closely. The goal of the CT is to have clients recognize the distorted thinking and reframe the held core beliefs about themselves and the world around. For treatment to be successful, faulty cognitions will be replaced with appropriate thinking and as a result clients experience cognitive, emotional, and behavioural changes (Beck & Weishaar, 2011; Mash & Wolfe, 2005). The CT utilizes both cognitive and behavioural techniques to facilitate client change (Beck & Weishaar, 2011).
CT uses a structured set of techniques to encourage the client to identify and test their dysfunctional cognitions (Corey, 2009). The techniques used in the CT techniques are divided into two major categories: techniques used to locate and investigate automatic thoughts and techniques used to identify and analyze the validity of maladaptive underlying assumptions (Young & Beck, 1982). Some of the techniques I use with clients to identify and examine the maladaptive cognitions are Socratic dialogue, role-playing, and guided discovery techniques (Beck & Weishaar, 2011).
CT uses not only cognitive, but also behavioural techniques. I use verbal techniques to identify my clients’ thought patterns, analyze their train of thoughts that identify irrational thoughts (Beck & Weishaar, 2011; Mash, 2006). For example, I ask them questions pertaining to situations where they felt upset. Once they identify their thinking at that specific time, we start working on identifying the dysfunctional thinking. I do not interpret their thoughts, but rather explore the meaning of those thoughts with them. CT involves learning new skills and therefore learning and practice outside the therapy session represent an essential part of the treatment.
I use ET with clients in their final stage of therapy as well as with low resistance clients. ET assumes that the central problems people face is embedded in anxiety over our ultimate concerns: loneliness, isolation, despair, and, ultimately, death. I believe that my clients’ anxiety is generated by this inner turmoil that we all come to experience. The goal of the therapy is to help clients discover barriers in their life and to take responsibility for their actions (Yalom & Josselson, 2011). I focus on building strong relationship with my clients based on empathy and I use their dreams as potential metaphors for the inner meaning of their life (Yalom & Josselson, 2011).
Success. Empirical support for CT is strong (Mash; Wilson, 2011) and interventions are evidence-based practices. According to the cognitive therapists, it is important to demonstrate changes in cognition and behaviour that place individuals within the boundaries of normal developmental, sociocultural, and personal functioning (Mash, 2006). A large body of research support the efficacy of CT and a plethora of literature supports the use of it for a wide range of clientele (Beck & Weishaar, 2011; Corey, 2009; Mash, 2006; Mash & Wolfe, 2005).
On a different note, ET tends toward an epistemological pluralism criticizing other therapies for displaying favoritism toward quantitative or objective research. Additionally, there is little research and usually the ETS is integrated within other frameworks to hold positive and stable results.
Contextual factors CT is based on empirical evidence and can be considered evidence-based practice (Beck & Weishaar, 2011; Corey, 2009; Mash, 2006). CT is effective when used with clients who experience depression and anxiety. Others have noted that CT can be use effectively in setting such as: individual therapy, short or long term therapy; marriage therapy; and for childhood therapy and problems within the classroom (Pledge, 2004).
Research based on ET indicates individuals with low levels of perceived meaning in life may be prone to substance abuse as a coping mechanism. Frankl (1959) first observed this possibility among inpatient drug abusers in Germany during the 1930s and later, Nicholson and colleagues found that inpatient drug users had significantly lower levels of meaning in life when compared to a group of matched, non-user control subjects (Nicholson et al., 1994). Shedler and Block performed a longitudinal study and found that lower levels of perceived life meaning among young children preceded substance abuse patterns in adolescence (Shedler & Block, 1990).
Reflection
Weakness of personal theory. A weakness of the cognitive approach is that therapists can become too directive and overlook the client’s voice in the therapeutic alliance. According to Corey, therapists can influence clients toward ways of thinking or making behaviour changes that the client did not choose or is not comfortable using. Another criticism is that cognitive approach can be overly prescriptive and does not address life concerns that existential therapists address (Corey, 2009). The role of anxiety is viewed differently by the two therapies. Cognitive therapists believe that anxiety is unhealthy, whereas existential therapists believe that anxiety does not necessarily is unhealthy. Existential perspectives value the journey through the suffering, purport there is meaning, and growth associated with this journey. Any quick approach to alleviating suffering runs the risk of being counterproductive.
Conclusion
I currently identify most with the technical integrative approach that combine cognitive therapy and existential therapy. CT provides a framework to understand the development of maladaptive thoughts and ET provides a framework to understand the development of self-awareness. I believe CT and ET provided effective evidence-based interventions to use when working with a mosaic of clients with various psychological needs.
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