If Your Therapist Is Not Doing This, Ask Why.

Many people who turn to therapists for recovery have a stereotyped imagination of what they can expect from the experience. Many have the image of a Freudian like character sitting in a leather chair, saying nothing and occasionally coming out with some masterpiece of intellect that brings realisation. While it can be said that this is true in some cases, CBT therapists employ a much more flexible, hands-on approach that calls for challenging clients belief systems in various ways. This disputing of the client’s  “window of reference” is sometimes hard for the client to take but is an essential part of a CBT therapist’s approach.

In general terms, the word ‘dispute’ carries a negative connotation associated with conflict, argument or row. In CBT, disputing means challenging the client to see irrational beliefs as unrealistic and encouraging  them to replace these with more rational, realistic versions. The aim is to replace long-standing false beliefs with a client driven flexible belief system in order to help them become less disturbed.  Clients often have problems  adopting this ‘verbal persuasion’ and sometimes change is only initiated over a long period. CBT therapists challenge clients in what is known as ‘multimodal disputing’. This means that it can take place across four spectrums. These being, cognitive, behavioral, imaginal and emotive. While these are all equally important in terms of the bigger picture and interdependent of each other, CBT therapists  will work mostly on cognitive disputing as this is seen as the ‘first among equals’. The aim of cognitive disputing, through interaction between client and therapist, is to lead the client into an atmosphere of self disputing and in essence to eventually become their own therapist. Disputing is generally done in five ways.

1. Rigidity versus  flexibility:

Classic all or nothing thinking, e:g, I must, I should and when not, my world will end. Therapists can challenge this thinking, making it more flexible meaning having strong desires but being prepared for setbacks.

2.Extremism versus non-extremism:

In other words, awfulizing. This means associating failures and setbacks with a generalized view that this setback proves the irrational thoughts around worthlessness and hopelessness correct. Non-extremism accepts that these failures makes things more difficult but they are not life-threatening.

3.Logical Reasoning:

This form of disputing is aimed at showing the client that feelings are not facts, e:g I feel terrible so I must be terrible. The goal is to show the client that there is no logical reason for these kind of thoughts by questioning the evidence for it.

4.Empirical Disputing:

A therapist can challenge a client to provide evidence that their demands on the world are realistic. When clients are perfectionist and expect  their demands to be fully met by themselves or someone else, questioning and experimenting can lead to more realistic beliefs. Some clients can also be  convinced that something terrible will happen to them…this can also be disputed using this technique.

5.Pragmatic disputing:

Clients who hold onto irrational beliefs over a long period often make these beliefs part of their personality or judgment system. By using ‘common sense’ questioning, a therapist can cast doubt on the wisdom  of holding onto these beliefs.

Novice CBT therapists often find the essential skill of disputing difficult in a number of ways.  Firstly, choosing the correct type of disputing can be difficult and  also which problem to dispute first. Secondly, it would be easy for the novice to be too directive with a client, get wrapped up in jargon and get lost when the standard approaches bring no result. One of the main criticisms of CBT is that therapists tend to talk too much and be too directive when disputing.

We have seen that cognitive disputing is often the first approach for CBT therapists. That is not to say that the other three mentioned earlier are not also important. It is wrong to assume that working on these will have an effect on the others but it can happen. Behavioral disputing challenges clients, usually in a homework exercise to change beliefs about behavior that is perhaps causing anxiety or relationship difficulties. Some clients respond better to visualizing their irrational beliefs in the form of images. Imaginal disputing uses such images to show the client the full force of their belief and then an image of how it might look when the belief was no longer there. The final and seen as most difficult is emotive disputing. The most recognized techniques here are the ‘shame-attacking ‘  exercise where clients are encouraged to act in exactly the way they fear in order to show that they over-exaggerate the reaction of others. Another technique is the ‘self-disclosure’ exercise where clients disclose information to others that they have kept hidden.

  12 comments for “If Your Therapist Is Not Doing This, Ask Why.

  1. January 30, 2018 at 7:22 am

    Therapists like you that have gone online, are a great resource. Most clients have no clue what to expect in therapy.

    Sharing the goals a therapist is pursuing is essential. I always have purchased the therapists version of the books I have read if available.

    Knowing the purpose, the reason a therapist uses a certain therapy, gives insight to healing.

    Could you also share what a client should look for in a therapist?

    My thoughts are that at intake,we sufferers should be evaluating the therapist as a match or we need to keep looking. How long do we stay with a therapist without improvement.

    I run across people who will say I been in therapy for 17 years. I asked did you ever considered this therapy has failed? Never entered there mind.

    Also, I believe the client has an obligation to work and the drive to heal is all theirs.

    One last thing. Cbt is a dominant therapy but has proven ineffective with PTSD.

    It has worked well with a hybrid, a CBT blended with mindfulness, ACT AND DBT.

    Thanks for sharing.

    Marty.

    Like

    • January 30, 2018 at 7:27 am

      This would be an excellent subject for a new post and I will certainly do this. I like the comment regarding CBT. While I like it as a method, I very rarely use it without combining it with other methods to tailor an approach for the client. Thank you for the comment, as always.

      Like

      • January 30, 2018 at 7:32 am

        You do a good job doc, this medium reaches far more than you think. Like talk radio few call in, millions listen

        Our effort and attitude is all we control, I believe.

        Thanks for your sharing and guiding those who need help.

        Liked by 1 person

      • January 30, 2018 at 7:32 am

        Thank you Marty

        Like

      • January 30, 2018 at 7:34 am

        Also, why not give a look at how therapy impacts a therapist. You listen to peoples problems, trauma, issues all day. As cops and emergency people also get PTSD from repeated contacts.

        What do you have to do for self care?

        Like

      • January 30, 2018 at 7:38 am

        This is a very important aspect of the work we do. I have recently just come back from vacation and it was the first time ever that I didnt take my work with me. Those type of boundaries have always been difficult to enforce when you know people need help. However, they must be set and a way must be found to come out of the helping world occasionally. In the long run, this is beneficial for all concerned.

        Like

  2. January 30, 2018 at 12:41 pm

    Yes! The work I did with my therapist in challenging my beliefs has become part of me now; it’s just what I do. I learned to identify the beliefs behind my thoughts and behaviors and how to “dispute” them myself to discern whether they are realistic beliefs in the circumstance, or if perhaps they are limiting me in some way. Very valuable skills.

    Like

  3. January 30, 2018 at 12:55 pm

    A book for clients to navigate therapy and therapists is much needed.

    How to choose.

    How to evaluate if this therapist is competent, has multiple therapies or has only one approach.

    How do we select?

    Hard to find any info on what works and how long in a general way does healing take. Well good improvement if healing is possible. I come across those who think real healing is impossible.

    Let’s take PTSD

    What therapies work best?

    I have searched and info on results elude me. I know personally what works best but I am well read and have worked my way out complex ptsd and agoraphobia.

    I was clueless when I started.

    I bet a client has never entertained that they are the quarterback of their healing.

    Most clients give to much power to a therapist and never consider leaving or changing.

    When you run across a therapist like you, the difference of your skill level and approach are clear, well to me.

    Lot of therapists books out there.

    This is a subject untouched

    Like

    • January 30, 2018 at 7:58 am

      Great idea, I am shocked nobody has thought of this. However, it might be complicated by the fact that some conditions might need very specific treatment. I do see the value of a general guide to choosing a therapist.

      Like

      • January 30, 2018 at 1:11 pm

        Sharing from a novice, me, when I started, to now, I run a ptsd/mindfulness blog plus runs mindfulness group for NAMI, a big. Void exists

        After I improved, an idea came up. I had to fill in all the time that was spent dissociating, avoiding, etc.

        I knew how lost I was when my chronic pain phycologist said I had complex PTSD. Took me six months to figure out what the hell it was.

        Then how,do you go about healing.

        Parts of the brain are offline with PTSD at times so therapy is impacted by time distortion, triggers and extreme fear.

        I started my blog to fill in this craters. What I had to search for I provided a path, not the only path but direction and insight.

        A book like this will be a big seller.

        No competition.

        Also this is the most unknown part of searching for help and if you choose incorrectly healing is impossible.

        Just think how few search out a therapist and how so many fewer would search out the second or third therapist or therapy

        I almost exhausted therapies before mindfulness packed inside ACT appeared.

        The other thing is therapists need to apply pressure, demand work during the week

        We are in therapy maybe a hour a week,
        4 hours a month compared to 669 hours on our own.

        We heal doing the work between sessions

        Liked by 1 person

      • January 30, 2018 at 8:18 am

        Certainly food for thought

        Like

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