While my theoretical orientation lies with cognitive-behavioural therapy (CBT), it would be incomplete to leave matters there. I conceptualize human behaviour as resulting from the interaction between learned patterns and interpretations and beliefs. I value the flexible nature of CBT and the collaborative and educative stance taken with clients. However, my identification with the CBT model is strongly due to the depth of supporting empirical evidence. I have a duty to my client to provide them with the best services of which I am aware. I would much rather provide my client with a non-Cognitive or behavioural based service that is supported by research, than blindly provide CBT out of habit. It is not “what works” that matters as much as “what works for whom”.
The influence that CBT and evidence-based practice has upon my case conceptualization and intervention is evidenced in the case of “Paul” (see Wanklyn, Brankley, Laurence, Monson, & Schumm, 2016). Paul’s symptoms met criteria for post-traumatic stress disorder (PTSD) and alcohol dependence. He had previously engaged in alcohol-focused interventions, with little success. My co-therapist and I hypothesized that Paul’s drinking was a trauma-related form of avoidance and recommended he take part in treatment that targeted both problems.
Creating flexibility in Paul’s beliefs about himself in the context of PTSD and alcohol use was important to his recovery. Paul identified as an “alcoholic” first and endorsed a belief from Alcoholics Anonymous that a year of sobriety should be achieved prior to addressing other problems (e.g., PTSD). I suggested he complete a cognitive worksheet to examine the benefits and risks of treatment and termination. This was a critical point, as Paul later pointed out after he successfully completed treatment—he came to the next session committed to treatment because he believed that he needed to face his PTSD in order to be free from his need for alcohol.
Non-CBT models that have empirical support may have incremental value to CBT. For instance, I found psychodynamic theories helpful in conceptualizing the therapy interfering behaviours of an adolescent client who lived with Borderline Personality Disorder. Despite our strong overall alliance, he would become so hostile at seemingly random points that session content could not be covered. I could not identify the stimulus. My supervisor suggested I consider how transference may provide complementary, rather than conflicting, interpretations for my CBT-based formulation. Because I knew the client’s developmental history, I hypothesized that some part of our interaction triggered learned responses from his childhood attachment figures (i.e., transference). The frustration I experienced was counter-transference, and helped me understand why this client rarely received support from others. To break the pattern in this psychodynamic-based interpretation, I decided to be dialectic in my responses: I validated his emotional distress at first and then I adopted an irreverent stance. By pointing out the unexpected consequences of his comments or extending the focus of his comments to extremes, his emotional intensity reduced and he became willing to participate in session.
My theoretical orientation reflects my attitude of placing clients first and ensuring integrity in the treatment I provide. I want to learn about the best evidence-based models for problems, whether or not they are based in CBT. For example, I have proposed a hybrid cognitive- behavioural/interpersonal model used in the treatment delivered to Paul for use amongst individuals convicted of sexual offences (Brankley, Seto, & Monson, 2016).
