In Fear of coffee I mentioned the renowned American CBT therapist, Christine Padesky. One of the recurring themes in her work has been to counter the notion that CBT is just about providing helpless patients with techniques for solving their problems, by emphasizing that patients always come to therapy with capabilities and strengths of their very own.
Padesky continues this theme in recent publications and lectures. Her recent forum post links to an open access article in Clinical Psychology and Psychotherapy, written together with her long-term collaborator, Kathleen Mooney, which outlines an approach to Strengths-Based CBT:
This approach goes back many years. For example, the same presenters ran a workshop in Auckland, New Zealand in 2006 with the title: Uncover Strengths & Build Resilience Using Cognitive Therapy: A Four Step Model And a handout from a US conference in 2009 gives quite a lot of detail: Identify Client Strengths to Build Resilience
The recent paper is briefer and clearer, and it links CBT with what is called positive psychology:
When CBT and positive psychology intersect, the question is prompted: ‘Is it possible to use CBT methods not just to ameliorate distress but also to promote happiness, resilience, courage and other positive qualities?’
There’s a major change of emphasis here. Previously, CBT was presented clearly as a form of psychotherapy for treating certain very common forms of mental illness. Resilience was seen as a useful component of the therapy that helps people to move on in their lives after being patients, and to prevent relapse.
Now, resilience is presented clearly as a way to enhance the everyday lives of people who are not ill. The CBT model is seen as a methodology for developing it:
We consider resilience a process, not a trait, and define it as the ability to cope and adapt in the face of adversity and/or to bounce back and restore positive functioning when stressors become overwhelming
The four-step model of CBT for resilience parallels the standard approach to CBT as psychotherapy, although the middle column in this table is just my interpretation, not a quote:
|CBT as psychotherapy||CBT for resilience|
|Step 1:||Therapeutic alliance||Understand client’s strengths|
|Step 2:||Formulation||Construct personal model of resilience|
|Step 3:||Treatment plan||Apply the model|
|Step 4:||Treatment||Practice and experiment|
I think the paper makes a reasonable case for this approach in its few pages. As usual in Padesky’s writing, the examples of conversations between client and therapist cleverly illustrate how they see things in different ways:
Paul: (complaining) My supervisor was really rough on me this week.
Therapist: I’m sorry you had a rough week, but in a way that is lucky for us (smiles).
Paul: What do you mean, ‘lucky’?
Therapist: Well, we wanted you to have a chance to practise being resilient…
Such a short article can only be expected to cover the basics, yet some references to weaknesses in the approach would have been welcome. The article acknowledges lack of research in this area, but a few other things jumped out at me while I was reading it.
Positive human qualities
Positive psychology gets only a passing mention, and there’s an assumption that everyone knows “positive human qualities” when they see them. But research in positive psychology has shown that’s not the case.
For example, an early assumption in positive psychology that people simply seek happiness turned out to be false. What people want out of life can be complicated and counter-intuitive, and any approach to resilience would be stronger for considering this question more deeply.
Examining the way CBT is commonly practised suggests how resilience will be practised, if the idea gains ground at all. Many therapists will do no more than take the word “resilience” and use it in to describe what they already do, without changing their approach to clients one iota.
For example, the term “CBT” is widely used by a variety of practitioners, some of them well-qualified in other things like counselling and psychology, whose clients never experience anything of a genuine cognitive-behavioural approach. It would have been useful to list some of the common approaches to therapy that prevent resilience, as a way of emphasizing that resilience is not simply an invitation to re-jargonize existing practice with a sexy new buzzword.
Even if some therapists do attempt to use this strengths-based approach, many of them are likely to avoid the hard parts, Steps 1 and 2, which are understanding the client and constructing a personal model of resilience:
Therapist and client then co-create a PMR on the basis of the strengths identified and written down during the search phase.
Not likely — that’s hard work!
Just as there are therapists who try to do CBT from a blotchy seventeenth-generation photocopy of a formulation for someone with depression that was once given as an example in the textbook of CBT their course tutor wrote, ignoring the client in front of them, so there will be therapists who try to do resilience with a PMR from the filing cabinet too. It would have been useful to see a clear explanation in plain language of why this won’t work, why resilience means different things for different people.
Still, despite some lack of clarity in the presentation, this is an intriguing development. Padesky remains one of the very few in the world of CBT to consistently push the boundaries without losing the plot.