I don’t screen my clients before our first meeting. My office has instructions to make an appointment for anyone who wants one. If people ask if their problem is something I can help with, my office tell them that, presuming their problem is psychological, they should make an appointment, as we will almost certainly be able to help. Theoretically we could get inappropriate self-referrals, in which case we would refer on and not charge for the session, but this rarely happens.
I treat those clients with definable problems, such as panic disorder, OCD, and depression, according to the NICE Guidelines and in line with current CBT research. However, many people present with difficulties which relate to their environment: family, friendship network, and employment. Others present with problems relating to their age and stage in life. I also notice that even those clients who present with definable psycho-pathology often seem to want to raise social and life stage issues as their condition improves.
I’m increasingly consulted by older people, many of whom want to talk about the necessary losses and existential challenges of old age. You could argue that they have a form of adjustment disorder, and that what we are doing is a form of cognitive restructuring, but such a framework of understanding unnecessarily constrains the work we do with this group, which can really enhance their quality of life.
Early in my career, an elderly man came to see me. At our first session, he politely declined to identify a psychological problem, saying that he was just about to retire and would like to talk things over. He came for several sessions. He talked. I listened, and made some minimal observations. I put what he said into the generic CBT framework of thoughts, feelings, emotions, behaviours and context. I observed his schema, although I cannot recall whether I used that term with him explicitly, and I identified what cognitive distortions I could. I don’t recall, but I also probably discussed some of the key ideas from Stoicism. My supervisor of the time was adamant that what I was doing was not CBT because I had neither clear goals, not a well-defined endpoint, and the client didn’t have any condition that appeared in the DSM. I took my supervisor’s concerns back to my client. He said that he was finding what we were doing very helpful. He pointed out that, since he was paying, he couldn’t see the problem. This chap probably consulted me over perhaps a handful of sessions. On the one hand, he seemed to be non pathological, and yet on the other, he seemed to benefit hugely from our work together.
If a client is self-funding, and we are clear about what they are offering, I don’t think there is an ethical issue if we provide conversations which explore and problem solve within a CBT framework, even when we do not identify any specific pathology. Sometimes defining the problem over several sessions is the therapy. If we only work with clients whose pathology is immediately identifiable and insist on a clear pathology focus, there is a strong likelihood that we will just coerce them into adjusting their presentation to suit our needs. This is what sometimes happens in the NHS with all sorts of conditions. When I had a small benign growth which I wanted removing for cosmetic reasons some years ago, I knew that the NHS generally doesn’t fund cosmetic treatments so I said that the protrusion the growth caused was rubbing and causing discomfort. This is all very well, but if you have one problem and seek treatment for another, the treatment is less likely to be effective. Many of the people I see have had their problem for many years. They have presented to GPs, and other healthcare providers on many occasions, resulting in wasted healthcare resources and a demoralising experience for the person concerned.
My private clients come with issues which they might have taken to someone offering a more generic counselling approach in the past. These folk know about CBT and they want help from this perspective. Yes, they want to be listened to, but they also want consultation, collaboration, problem formulation, and they want to take action. If you like, they want something similar to what we therapists have in our clinical supervision.
Our social welfare system makes a distinction between social care and health care, where the NHS funds one, but not the other. NHS provision has also always tended to emphasise alleviating sickness rather than promoting health. These biases exert a big influence on mental health care, including mental healthcare outside of state provision, and I suspect they even bias our own thinking as mental healthcare practitioners. CBT perspectives already inform a huge amount of personal development, self-help literature. There are books on assertiveness, couple skills, and stress at work, yet our clinical work is still very pathology oriented. I think we should be developing our range of interventions to encompass human unhappiness in all its manifestations not just psychopathology. We should be allowing people to define their unhappiness in their own terms. As independent practitioners, we have the flexibility to offer to develop and promote non-pathologising mental wellness services, when colleagues in the NHS perhaps don’t.
Adam May is a BABCP accredited CBT psychotherapist living and working on Anglesey, in North Wales.