Imagine that a student did not do his college work or suf®ciently prepare for his examinations; it would not be surprising if he did not do well or even failed his examinations. The problem may not have anything to do with his intelligence or ability; it is more to do with his commitment and effort. However, he may come to label himself as stupid and useless and become pessimistic about his future.
CBT is generally regarded as a `talking' therapy. However, CBT considers that action is at least as important as talking, if not more so. In this respect, CBT is also regarded as an `action' therapy. When clients are not `practising' homework with effort and commitment and are not making progress, not only would they become pessimistic about their progress and their future, but also they may label themselves as failures and useless. This may have the unwanted effect of reinforcing the notion of mental health problems being caused by chemical imbalances in the brain and genetic factors. Bobby, as described here, said that `there is something wrong in my brain' and believed that drug treatment was the only way to `make it right'.
The case of Bobby
Bobby was doubtful about the idea of another referral to psychotherapy. He believed that drug treatment was the remedy for his anxiety and that his
problems could not possibly be resolved through talking. Although he had been on a range of drugs of various dosages for most of his adult life, he just managed to stay `above water'. His anxiety and associated bodily sensations were particularly bad in the mornings and there were no reasons for them. There must be something wrong with him physically. The idea of `chemical imbalance' being the cause of his anxiety problem was appealing. It seemed reasonable to attribute his bodily sensations of anxiety to an insuf®cient level or dysfunction of neurotransmitters in the brain, like people suffering from Huntington disease or multiple sclerosis.
`I don't want to sound negative or pessimistic, but I don't think that it will work for me,' said Bobby, who was sceptical about a referral to CBT for the second time. `Medication is the only way to help me to recover.' His consultant psychiatrist truly believed that his negative outlook was largely the problem and medication was an adjunct to CBT work. After ®ve CBT sessions, there was little or no progress being made and he was both disappointed and frustrated. He did not see the relevance of doing homework (e.g. reading articles, reality testing) as a way of helping with his anxiety problem, although he did do it in a super®cial manner.
The idea of homework is not just to get clients to read articles relevant to their mental health problems, to do reality testing to see whether there is evidence to support his negative thinking, or to change negative thinking to positive. Changing their unhelpful (or maladaptive) behaviour is as important, if not more so. For example, positive change comes about as a result of being able to express feelings, opinions and preferences, or to say `no' reasonably and appropriately to requests, or to make a mistake and learn from it. Although intellectually understanding that it was the right thing to do, Bobby did not make any attempt to change any aspect of his unhelpful behaviour such as avoiding con¯ict, perfectionism, procrastination and self-criticism. It was therefore not surprising that he was both frustrated and disappointed with the lack of progress in his treatment.
I was equally disappointed and frustrated with his lack of progress and made it clear that `there was no magic wand' to aid his recovery. It required hard work and commitment from both of us, particularly at the level of changing unhelpful behaviour. I said to Bobby that unless he was willing to take responsibility for his recovery and to work hard with me to achieve our objectives, continuing the therapeutic work at an intellectual level would accomplish little or nothing at all. When there is insuf®cient or lack of progress after ®ve sessions, it is worth examining the possible reasons; not changing unhelpful behaviour is often a major contributor.
Bobby was pleased with himself for being appropriately assertive in his complaint about the standard of food in a restaurant and said that he wouldn't have done it in the past, for the same reason as that of his wife. His wife was anxious about the possibility of an angry reaction from the waiter and urged him not to make a fuss. In subsequent sessions, he reported the efforts being made to change his unhelpful behaviours at every available opportunity and learnt from the experiences of failure. As a result, his rising self-con®dence had helped to bring down his anxiety level. His change is surely an inspiration to other clients with mental health problems. It also illustrates that the hard work put in to `doing' and `practising' homework is necessary. Positive change can't happen by chance.