Beliefs Can Interfere with Treatment Adherence

[David Baxter PhD]

Beliefs Can Interfere with Treatment Adherence
by Judith S. Beck, Ph.D., Director, Beck Institute
Monday, July 13th, 2009

I recently read an interesting case description on a professional listserv about a ?difficult? client who was not fully adherent with treatment. Apparently he argued with his therapist and did little homework outside of the session. It was apparent to me that the therapist had made a mistake. She was continuing to try to deliver ?standard? CBT treatment, without attending to the therapeutic relationship sufficiently. I hypothesized that the client had an interfering belief:

?If I refrain from arguing with my therapist and comply fully with treatment? [something bad will happen or it will mean something bad about me]".​

I don?t have enough details about the case to understand how the client would finish this assumption, but some clients might answer:

?I?ll feel so distressed that I won?t be able to stand it,? or ?it will mean she?s in control, and I?m not.?​

Until such interfering beliefs are elicited, evaluated, and effectively responded to, this client is unlikely to make much progress.

 

[Ryan Howes]

This is a great example of resistance. But I think it's just the beginning of the discussion. We have to look at what happens next, after the irrational belief is recognized.

This takes us to the intersection of cognitive therapy and dynamic therapy. As CBT founder Donald Meichenbaum said: "[we ask] WHAT and HOW questions. WHY questions are NOT very productive." A dynamic therapist wants to explore why first and foremost, then they'll get around to the what and how, if they need to.

To clarify: in the above scenario, CBT will look at the client's resistance as a problem with an irrational belief - "it will mean she's in control and I'm not." The digging stops there. We'll reframe the belief and move on with the intervention.

A dynamic therapist would ask why, wanting to know why there is resistance to authority, when he first felt the same way, who represents the reviled authority and what impulse he wasn't able to express to him/her. Dynamic therapists believe that understanding the original conflict will free the client and allow him to freely choose without fixation or compulsion. By making the unconscious conscious, the client gains freedom.

To oversimplify: CBT therapists view "why" as a waste of time, dynamic therapists view CBT as a bandaid for deeper issues that will return if not treated.

Just letting you behind the scenes of the theory wars.

 

[David Baxter PhD]

And of course there's no reason that CBT and other therapies cannot be combined...

I view CBT as useful (essential?) primarily in helping the client to acquire tools to deal with the immediate crises (and subsequently to address the early warning signs of a disorder or issue, as in major depression, OCD, bipolar disorder, etc.). Once that crisis has been brought under control, we add in elements of other therapeutic approaches or strategies, tailored to the individual's needs, goals, and circumstances.

 

[ladylore]

To oversimplify: CBT therapists view "why" as a waste of time, dynamic therapists view CBT as a bandaid for deeper issues that will return if not treated.

I have been very luck in the past few years to have had both. Neither one of these approaches on there own would have help solve some of the problems I was having. I had to change my thinking and get to the root of the problem, which was my childhood circumstances.