Wednesday, 9 June 2010

Level 5: Only Human

In the unlikely event that a client was completely ‘sorted out’ through therapeutic work at the first four levels (their lifestyle fully balanced, all their irrational anxieties lifted and maladaptive schemas healed!) there would still be serious issues facing them, because that is part of the condition of being human – all the more so, in realistic cases. Dealing with this aspect of therapy is the last level that needs attention to complete the Integrative CBT model.

Focusing on what it means to be human is of importance to the therapy process in at least three ways. First of all, it can help the client to more deeply understand their vulnerability to the problems they have grappled with; not just why they are individually vulnerable to depression, or addiction, or relationship difficulties, but why human beings in general are vulnerable. This can be a great help with the process of normalising and de-stigmatising problems, and developing self-compassion. It can also help clients put their struggles in a broader context, giving them some meaning.

The challenges of being a human are unavoidable in many different ways. As with any organism, we are exposed to risk, loss, old age, and death. More specifically, it is in the instinctive nature of the human species to have an unhealthy appetite for sugar, fat and salt, to experience ongoing anxieties regarding status and resources, and so on. The challenges of life may also vary with gender, age, and environment, as well as within different cultures and subcultures.

I think putting some focus on the nature of human nature is of particular importance in therapy, and I will say a little bit more about it below. For now, let’s just say that it may be important for clients to know that ordinary, non-pathological, humans sometimes feel sorry for themselves, are sometimes angry with people they care about, sometimes think life might be pointless, are sometimes attracted to people other than their partner, sometimes fantasise about being violent, sometimes shout at their children, sometimes worry about the future…

Secondly, focusing on the human level can help the therapist and client with the task of planning for the client’s future in a pragmatic way, based on a realistic view of what it is to be a human facing the particular circumstances this client is facing. Not everything is possible for everyone, and limits are set by factors such as age, resources, previous choices, personality and values. The fact that therapeutic planning happens within limits isn't necessarily bad news. Working within limits is where the creative action is; ask any artist or composer – or any recovering alcoholic.

Thirdly, some view of what it is to be human is implicit in every approach to psychotherapy, and should be made as explicit as possible. A view of the human condition is not just something that we come to at the end of therapy, but a theme that runs right through the process, and influences what both client and therapist believe to be possible. The personal philosophies of being human which can be found amongst clients and therapists obviously vary enormously, from new age to existential to scientific to religious fundamentalist etc. My own assumptions are already showing in the first sentence of this week’s blog: I’m obviously assuming that complete healing is not possible, or at least extremely unlikely - I see this as realistic, some might see it as pessimistic!

Along with this, there are the formal psychological theories of human nature on which any therapeutic approach is based, for example the optimistic, growth-oriented perspective of the Humanistic approaches, the relatively pessimistic Freudian view, or the pragmatic, scientific model of most Cognitive-Behavioural schools.

Since the role of the therapist is to help the client towards a greater understanding of themselves as a human being, incorporating whatever philosophical, cultural, scientific, existential, or spiritual perspectives the client finds helpful, the best that can be done is to discuss these issues explicitly at appropriate points in therapy (by raising the question of long-term goals, values, etc). Client and therapist do not have to fully agree, though too great a difference in views may simply not work for the client (especially in relation to value-laden issues such as abortion, pornography, etc).

My own preference is to incorporate the evidence-based findings about human mental health provided by psychological science. Since clients are coming to me partly for professional expertise in just such areas, this seems appropriate. For instance, I find it useful to educate the client a bit about Evolutionary Psychology, especially when working with anxiety problems (by explaining that anxiety has a function, that it evolved for a reason, that it doesn’t always work well in modern environments, etc), as this helps to humanise problems, making expectations more realistic.

One writer who is very good on this compassionate humanising of experience, especially in relation to shame and self-criticism, is Paul Gilbert, author of Overcoming Depression, and various books on Compassion-Focused Therapy, etc. See this link for one of his articles.

In next week’s blog, I will be outlining a first case example in order to give a bit more of a flavour of how Integrative CBT can work in practice.

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