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How do I address thoughts of being “a loser” that stop my client from using treatment techniques?

The therapist who suggested this FAQ told us how thoughts like “I’m a loser/weak for needing these techniques” were preventing their client from using grounding strategies or stimulus discrimination. These are good examples of “blocking thoughts”, which are important to identify as they can interfere with the effectiveness of treatment and lead to drop-out. In fact, it's often helpful to ask about any blocking thoughts when we introduce any new technique or set homework tasks, for example by asking “is there anything that might get in the way of you trying this?” or just “what do you make of that idea?”.

These types of thoughts are also clues to underlying beliefs a person might hold about themselves, other people and the world. For example, the client in this example might have broader self-critical beliefs about needing or receiving help or imagining that others would shame them. This was a male client who also reported that these techniques were not “macho”, suggesting they may hold important beliefs about masculinity, identity and emotions. These might link to earlier beliefs or longstanding schemas, often shaped by wider cultural influences and messages, and/or link to moments in the trauma where they felt weak or humiliated. As such, when these beliefs are identified, they are useful additions to our case formulations.

In terms of how to address them, we’d usually start by doing some digging about where these beliefs come from, what evidence they have to support them and how strongly they are held. Sometimes, some Socratic questioning leads to immediate shifts in beliefs. If not, we need to decide whether to use cognitive change techniques, like reviewing evidence, behavioural experiments, or surveys; or if we can work around the block by using an alternative technique. This is sometimes the quickest strategy and enables to move forward in therapy. However, we will almost certainly need to address a blocking thought if: it is blocking progress (e.g. if the thought “I am a loser” prevents the client engaging in any useful treatment interventions); it arose during the trauma itself (in which case it will re-emerge with re-experiencing symptoms or during memory work and will need updating); or if it links to a key belief in the client’s formulation and therefore will continue to emerge and likely cause distress in other ways.

Which cognitive technique we use will depend on the individual formulation. For example, if the client in question is frequently self-critical and believes others will think he is “a loser” if they find out he has PTSD and is receiving treatment, a survey might be a useful tool for accessing alternative perspectives about how people view receiving treatment for PTSD. We might examine his evidence for those beliefs. Perhaps someone in his close family or community has given him the message that receiving psychological therapy is somehow shameful. If so, treading carefully, we might examine that person’s reason for making that judgment and how much they could be considered a reliable source of information about psychological problems. If the client felt humiliated or ashamed during their trauma and had self-critical thoughts like “I’m pathetic for not fighting back”, we might use guided discovery to develop updates and integrate them back into the trauma memory. For example, perhaps not fighting back was a sign of dissociation (see related FAQ) or fighting back would have led to a worse outcome. If the client has a long history of low self-esteem linked to childhood abuse, we may work on schemas linked to poor self-worth using continua methods, historical reviews of evidence and, sometimes, updating or rescripting key childhood memories that seem to prop up the beliefs.

However, at times, we do not need to challenge beliefs, or at least change them completely, to work effectively with a person’s difficulties. We give an example in our book about a client who was a military veteran with strong beliefs about psychological therapy as “airy-fairy” and “wafty”. Instead of trying to challenge these, we agreed that he would try everything once but could veto anything he didn’t want to do. There were still plenty of effective ways of working together which he accepted. We also changed our language and adapted some of our techniques to suit him better. For example, the word “homework” had negative connotations due to bad experiences at school, but he was happy to do tasks in between sessions, which he called “ops”, in keeping with his military background.

The benefit of many of the techniques in CBT is that they can be personalised to suit an individual. Therapists sometimes forget this and present techniques in a “one size fits all” way. For example, we might give people a list of grounding or relaxation strategies or make suggestions, without asking them first what might help them reorient their attention or help them relax. Pre-ordained strategies can be off-putting for clients if it feels like they don’t “fit”, so we need to be flexible to make our interventions work for our clients. As long as we are tight to principles, we can be creative in our strategies. When it comes to grounding strategies, our clients use everything from calming essential oils to rubber chickens – whatever works!

All these interventions will be much easier if we have a strong therapeutic relationship with our clients. They should feel comfortable to tell us if something doesn’t suit them and know that we will be responsive. A good alliance also means that our clients might be willing to take a ‘leap of faith’ and experiment with techniques that they haven’t tried before. We can set up techniques as behavioural experiments with a win-win outcome of learning something new about what works for them. We need to demonstrate early on in therapy that it will be a collaborative effort and that we are open and responsive to feedback.

Key practice points

  • Blocking thoughts can interfere with treatment so are important to identify and add to the formulation

  • Some blocking thoughts can be addressed with cognitive change techniques, chosen depending on the client's formulation

  • However, not all thoughts need to be challenged; a block can sometimes be addressed by working around it, adapting techniques to fit an individual's needs and preferences

  • A strong therapeutic alliance helps for clients to feel comfortable sharing their concerns and to take a 'leap of faith' in trying something new

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