Mental Health Musings. A reflection on holistic clinical practice
With COVID an ever present variable in modern life, demand for mental health services is higher than ever. Many people are for the first-time experiencing grief and loss, or loss of agency over their personal circumstances. Arguably, this makes now a good time now to reflect back on what current clinical psychology really looks like.
Cognitive Behavioural Therapy (CBT)
When most people think of psychological intervention, often they think of one of two things; lying on a couch speaking aloud to an unseen and mysterious clinician enigmatic, or the strict skills-based teachings of manualised Cognitive Behavioural Therapy (CBT).
The reality of psychological intervention is neither as mysterious as the former, or as bland as the latter. Cognitive Behavioural Therapy (CBT) was initially created by Dr Aaron Beck in the 1960s. Beck was a psychiatrist well versed in the science of cognitive theory and behavioural theory, as well as the clinical application of psychodynamic practice. The CBT model was initially put together as a way to help psychodynamic trained clinicians to formulate patients using principles of cognitive and behavioural science. It gave a framework for clinicians to readily connect thoughts, feelings, and behaviours within the context of what is seen in the therapeutic relationship, to map out both their function and dysfunction. This paints a very different picture from the manualised skills training that CBT is typically thought of.
Acceptance and Commitment Therapy (ACT)
Fifty years have passed since the inception of this model, with many new modalities building upon the work of Beck. Jeffrey Young’s Schema Therapy provides guidance on how to better inform our formulations by taking into account the constructs of memory, learning theory, developmental psychology, and Hebbian theory. Likewise, Acceptance and Commitment Therapy (ACT) gives clinicians an appreciation of how values and core beliefs drive, and can divert our behaviour, and how we can feel empowered over our thoughts by practicing the mental gymnastics of cognitive diffusion (taught as “mindfulness”). This accumulation allows clinicians to better understand the relationships between thoughts, feelings, and behaviours. This means understanding how these relationships formed, why they have been maintained, whether the patient wants them to change, and how to change them via a variety of avenues. This information is collated in conjunction with observational information, such as a patient’s level of executive functioning, attention, affect, and perceptual disturbances to create a multifactorial analysis for the patient, our clinical formulation. It is not about skills training at all; it is about understanding of the self.
Building rapport, modelling desired behaviour, validating adaptive emotional responses, reducing defensive mechanisms in the room, adding much needed emotional and cognitive context to traumatic memories, and psychoeducation provides a foundation for more explicit and cognitive therapy for patients. This allows patients to learn how they experience the world, and are experienced by others, creating for ecologically valid change.
Has psychological practice really progressed much?
Reading the above, you might wonder, well what has actually changed? Has psychological practice really progressed much from Beck in the 1960s, given that he was already utilising psychodynamic concepts, such as transference, counter transference, and early childhood experiences, as well as the CBT model. The reality is that modern psychological intervention still resembles its 1960’s ancestor. The difference is in its empirical research base, allowing for modern clinicians to transparently assess, formulate, and communicate their findings and hypotheses to other practitioners using definable and testable constructs. This allows therapy to not only be holistic, but to remain faithful to the scientific method which drives psychology.
So, they got it half right, I guess 😊
David Evans MAPS
Psychologist, Clinical Intern
Astute Education & Psychology