CBT & Person Centred Therapy – Towards an Integrated Approach


I started my journey as a counsellor in a breeze block outhouse in Stirling University in 1978, the home of the student volunteer counselling service, known then as ‘Niteline’. Most of us were psychology students, equipped with good intentions, insomniac tendencies and a willingness to help. In exchange we got free tea and biscuits and a crash course in ‘counselling’. We dealt with the usual issues of any helpline, students away from home for the first time, social isolation, low self-esteem, exams, drug and alcohol problems, sexual assault, relationship issues, as well as those who felt that they just didn’t want to be at University any more. As a drop-in centre we had regular visitors, including those ‘worse for wear’, looking for company or a place to party. After some problems we had to stop offering the drop-in service as we were often on our own overnight, and this left us vulnerable.  I was aware of my lack of experience; and whilst I was able to listen, and that often provided the caller with some support, for many of our callers this was not nearly enough. I graduated from Stirling, moved to London, worked in Advertising and was lucky enough to work on some great campaigns, including the ‘Glasgow s’miles better’ campaign (anyone remember that?). I was also able to travel and worked in Taipei, Bangkok, Hong Kong, Sydney and Brisbane.

20 years on, in an ad agency in Brisbane I was approached by an organisation called ‘Lifeline’, a charity telephone helpline run by one of the Churches. It was led by a team of psychologists who offered face to face counselling and provided supervision and training to the volunteers. They wanted help to raise awareness for a youth suicide campaign and to help raise funds to train more volunteers. I felt a strong connection to the organization, and threw myself wholeheartedly into revamping their advertising, and encouraged suppliers to provide everything for no or low cost. We won awards and raised record amounts of donations. I also rediscovered part of myself that had been left behind in that breeze block
outhouse in Stirling some 20 years before. I didn’t need much encouragement to become a volunteer and spent a year as a volunteer telephone counsellor. Whilst I still enjoyed working in advertising, it became apparent that my passion had been reignited, and that my future lay in counselling.

So, at age 40 I came home, returned to university to do the full time post graduate diploma course at Jordanhill and loved returning to study. The teachings of Rogers (1951) made absolute sense; I was drawn intuitively to a person-centred approach; I felt that the core conditions were indisputable and that I had come home, intellectually as well as geographically. I began work as a counsellor in the NHS, and whilst I still felt it important to value and prize each individual, not to pathologise, label or pigeon-hole, it was a challenge to balance the demands of the volume of people looking for help, and the ability to provide effective support. There was a struggle to demonstrate the value of the services we offered, and to reduce waiting times. A push for accountability, assessments and short-term, brief counselling was a constant challenge to me as a Person Centred Therapist and the team I worked with at that time.

I left the NHS and joined an EAP, where the boundaries were clearer; we only offered short-term counselling, and assessment and accountability were already a given. Some 10 years on (and thousands of clients later) either as a Case Manager, or an Affiliate Counsellor, I have a healthy respect for a wide variety of modalities, and can also see some of their benefits and drawbacks. My thirst for knowledge has increased, and I have been drawn to “Mindfulness” and also (more controversially it seems) to CBT. It started with a weekend course in Manchester, which introduced the basic concepts.  How you think, influences how you feel, which in turn influences your behaviour. So, if you can
recognise and challenge those thoughts, then you can control the outcome of these feelings and behaviour. It seemed so straightforward and so evidence-based; I was curious and wanted to know more…

I was also reassured that it wasn’t just a passing fad. The idea has been around for at least two thousand years, with Epictetus who said that people are disturbed: ‘not by things, but by the views that they take of them’. Even Shakespeare seemed to be onto the idea that: ‘for there is nothing either good or bad, but thinking makes it so.’ (Hamlet)

I signed up to do a Certificate course, partly as an intellectual exercise, to further my own knowledge and awareness, and also to see if it would have practical application in my own life.  As a life long procrastinator – I wanted to test the theories out to see if I could elicit behavioural change in myself.  I was also curious to see if it was possible to offer a blended approach that offered the core conditions as a strong foundation to build a therapeutic relationship. To add mindfulness into the mix, to encourage clients to be aware of what their thoughts were, and then ‘borrow’ from CBT to help recognise unhelpful thoughts and be able work towards challenging and channelling them into something more helpful, or at
any rate less distressing. As a trainer, I also felt that CBT could provide more psycho educational tools and techniques to help manage stress or increase resilience in these sessions I did get a lot out of the course, both personally and professionally. I have learned that it is possible to moderate my own emotional responses to situations. Where previously I might have been less than tolerant, or procrastinate, I am now able to be more mindful of my own thoughts, and better able to challenge when I am being particularly hard on myself. It has been helpful in my relationship with my partner, and bringing up my daughter. Reminding myself that we are all fallible human beings, and that I am a good
enough mother, that I don’t need to be perfect, has helped my procrastination tendencies, and I am finally working on my accreditation.

It has also been helpful to understand that CBT itself is made up of a range of different modalities; it encompasses the theories of behaviourists like Skinner, Pavlov and Watson, who thought that behaviour is acquired and maintained in identical ways to the Cognitive work of Aaron Beck (1979). It was Beck who first put forward the idea that it was a person’s thoughts that played a significant role in the development and maintenance of depression. He invented the term ‘automatic thoughts’ (Beck 1979, p4, p30, p73, p87, p111, p147, 247-253). There is a strong emphasis on the therapy being collaborative. Beck states that: ‘it is useful to conceive of the patient-therapist relationship as a joint
effort. It is not the therapists function to try and reform the patient…’ Another important consideration is to reach agreement as to what problem requires help, the goal of therapy and how to reach that goal.  It is a problem-solving partnership. CBT is a more structured approach with the emphasis on getting clients to help themselves; this means that clients are often given tasks to do between sessions.  Tasks may involve self-monitoring of thoughts, feelings and behaviour. The self-monitoring is then examined in the sessions and the client is encouraged to look at alternative thoughts and beliefs. One of the main
things that I took away from all of this is that you are giving the client the tools to be their own therapist.

One of my problems is that I can see value in many of the different therapeutic approaches. That they all have their strengths and weaknesses, and that the usefulness of specific approaches depends where a client is in relationship to their psychological awareness or readiness to change.  I don’t believe in a ‘one size fits all’ approach to therapy, and it seems that if clients are asking: ‘can you help me deal with my
phobia about getting into a car…?’, then knowing that there is a tried and tested methodology to support this process, would seem appropriate for me to be able help them meet their goal. I would hope that my clients agree that I work with them collaboratively, that I consult, get feedback and review. With some clients I offer no more or less than myself and the core conditions, and that is enough, with others it appears that being more focused and goal-oriented is what is required. I describe this as an integrative
approach and have recently heard it described as ‘Pluralistic’. A colleague recently recommended that I read research by Cooper and McLeod (2007); together they seem have developed a new approach which starts with the assumption that: ‘different things are likely to help different people at different points in time’, and that therapists should work closely with clients to help them identify what they want from therapy and how they might get it.

This makes absolute sense to me, as I believe that the power to make changes lies within the client; as a counselor / therapist I am only there to facilitate that process. I am not there to be ‘the expert’; for therapy to work and be effective it is a meeting of minds, each possessing their own expertise, with goals and solutions created through agreement rather than prescription.

When I look back at my 20 year old self setting out in the breeze block converted laundry building in Stirling, knowing a bit about behaviourists, a bit about Aaron Becks theories, I feel that I have come so far. And yet, I am still in so many ways the same, still somewhat naïve, very optimistic, insatiably curious, with a strong desire to be the best that I can be and to help others do the same. I’d like to give Rogers (1961) the final word as I still have the fullest of respect and admiration for his work:

“I believe it will have become evident why, for me, adjectives such as happy, contented,
blissful, enjoyable, do not seem to quite appropriate to any general description of this process I have called the good life, even though the person in this process would experience each one of these feelings at appropriate times. But the adjectives which seem more generally fitting are adjectives such as enriching, exciting, rewarding, challenging, meaningful. This process of the good life is not, I am convinced, a life for the faint-hearted. It involves the stretching and growing of becoming more and more of one’s potentialities. It involves the courage to be. It means launching oneself fully into the stream of life. Yet the deeply exciting thing about human beings is that when the individual is inwardly free, he chooses as the good life this process of becoming.” (Rogers, 1961: 195-196)

I will continue to develop my ability to offer the core conditions, as well as adapt a more integrative or pluralistic approach. Rogers seemed to imply that it is a counsellor’s obligation to keep growing, and that it was a glorious invitation to live life to the full. I fully accept that invitation.

Kate Mollison

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References

Beck, A., et al (1979). Cognitive Therapy of Depression.
New York: Guildford Press.

Cooper, M., & McLeod, J., (2007). Counselling and Psychotherapy Research: Linking research with practice
Volume 7, Issue 3, 2007, 135-143. A pluralistic framework for counselling and psychotherapy: Implications for
research. DOI: 10.1080/14733140701566282

Rogers, C.R. (1961). On Becoming a Person, A Therapist’s View of Psychotherapy.