Richard Hallam on Schema-Focused Cognitive Therapy
On the future of mental health
Posted Apr 14, 2016
The following interview is part of a “future of mental health” interview series that will be running for 100+ days. This series presents different points of view about what helps a person in distress. I’ve aimed to be ecumenical and included many points of view different from my own. I hope you enjoy it. As with every service and resource in the mental health field, please do your due diligence. If you’d like to learn more about these philosophies, services, and organizations mentioned, follow the links provided.
Interview with Richard Hallam
EM: You began as a traditional cognitive-behavioral therapist, which is one of the more popular therapeutic orientations and the “standard” orientation in the UK. Can you tell us a little bit about the intentions and methods of cognitive-behavioral therapy?
RH: Actually, I began as a behavior therapist. At that time it was a problem centered, multi-leveled approach, which was more broad-minded theoretically, at least in the UK, than is commonly assumed. It was fundamentally opposed to a medical ‘diagnose and treat’ model.
It grew into cognitive behavior therapy (CBT), which unfortunately accommodated to demands to diagnose in psychiatric terms and to prove itself in randomized control trials against other "treatments." CBT broadened out very successfully as well, but has now begun to contract into an ersatz, abbreviated, manualised, and almost unrecognizable form that most old-timers hope will just be an embarrassing stage in its development.
I call myself CBT because I have to register with a professional body and because CBT is a very broad church. It’s popular with the British public largely because of what it is not, i.e., it doesn’t assume that you have to begin with the past and it is not a woolly kind of counseling that leads nowhere.
EM: You then moved on to working with people with life-long problems and the application of “schema-focused cognitive therapy.” What is schema-focused cognitive therapy and how is it different from “ordinary” cognitive therapy?
RH: Around 50% of people referred to an outpatient psychotherapy service in the UK National Health Service have enduring life-long problems that are often traceable to awful family situations or trauma. Aaron Beck’s first formulation of cognitive therapy was not appropriate for this group of people as he soon realized himself. Schema focused therapy adopts the strategy of slow behavioral change, targeting everyday interactions, and always relating the present to the past while being oriented to the future. It avoids the risk of an enmeshed transference/countertransference therapy relationship by sticking to identified problems and using fantasy and role-playing methods that permit both emotional engagement and reflective distancing.
EM: You are the author of the book Individual Case Formulation. Can you tell us its intentions and a few of headline points?
RH: Quite simply, everyone's problem is unique. The tasks a person faces, even from one day (or therapy session) to the next, can change according to circumstances. An idiographic approach that abandoned psychiatric diagnosis and investigated the parameters of a specified problem was established very early on in British clinical psychology. The approach now takes different forms.
Mine proposes guidelines for producing a phenomenological description of a problem that has to be clearly distinguished from any interpretation placed upon it. I suggest that interpretations or theoretical hypotheses can come from any orientation, and the problem is viewed from different perspectives - existential, theoretical, cultural, etc. There is an attempt to be systematic about improving one's understanding of a problem, a task shared jointly, of course, with the person concerned.
A therapist gathers and marshals the relevant information, develops ideas about how a problem is being maintained, and agrees with a person on how they want to proceed. Of course, this way of working is far too open-ended to appeal to agencies with a managerial mindset. However, I have found that some Health Insurance companies (and certainly many of the people I see) are not too concerned about labeling the methods I use if they are pleased with the end result.
EM: What are your thoughts on the current, dominant paradigm of diagnosing and treating mental disorders and the use of so-called psychiatric medication to treat mental disorders in children, teens and adults?
RH: The word revolution is grand but not out of place when speaking of the need for change in the present ideology of mental health. When Thomas Szasz raised his head above the parapet in 1961 and announced mental illness a myth, he attracted heavy hostile fire. In many ways, the myth is now more entrenched. Metaphors are wonderful fluid linguistic tools in the hands of poets but when a metaphor such as illness is applied to life itself, it begins to set like cement.
The Adam and Eve myth of human origins was eventually overturned when people realized they were closer to animals than gods. Although the Church lost this particular battle, I am not so sanguine about overturning the literal interpretation of the mental illness metaphor. It is supported by vast commercial, professional, and state interests, and it is believed by a large section of the population. However, as a metaphor that guides our way of thinking, we cannot place all the blame on others; it is necessary for all of us to change the way we think.
The myth mystifies the concerns people often have about the meaning of their life and why it sometimes gets messed up. Many of my clients abhor the idea that they might have a mental illness (the substance of bad dreams and horror films) and are adamant that they will not touch medication, which only serves to confirm their doomed status. However, with encouragement, most people can go about reshaping their lives.
A young woman who came to see me recently had been significantly depressed for six months and had refused medication. After her first session she reported that she didn’t sleep for four nights but reasoned that you had to get worse before you got better. In the second session her issues were clarified along with decisions she had to make. At the beginning of the third session, a month later, she announced that she had decided to change her job, she had received a good job offer (but refused it for valid reasons), she had dealt with a family confrontation she had long been avoiding, her partner had asked to marry her, and she had already arranged the date and place of her wedding in a year’s time. When asked if they were any grey clouds on the horizon, she couldn’t think of any.
Unfortunately, not everyone exemplifies such a positive spirit, which in her case had been submerged beneath a depressed mood. Why is it that more and more people are deciding, instead, to take anti-depressant medication? The annual rate of prescribing has been climbing steadily for decades. Occasionally, I have noticed that it is a sacrifice that serves to stabilize family dynamics. A spouse or family physician might put on pressure “not to come off the meds.” A recent research study discovered that the incidence and severity of depressed mood has not been rising and prescribing practices have not changed. However, a small proportion of people decide never to stop taking the medication. Consequently, the number of annual prescriptions continues to accumulate. This is an ideal scenario for any pharmaceutical company. You have a largely ineffective medication, the condition is chronic (or becomes so), and the consumer feels that they are benefiting.
EM: If you had a loved one in emotional or mental distress, what would you suggest that he or she do or try?
RH: There is a saying that you can take a horse to water but you can’t make it drink. A person has to look into their own circumstances and follow whatever clues they can find. Then, if they choose therapy, I think they should be led by their gut feelings about the person they eventually locate.
I think it’s also important for them to choose someone who claims to have expertise in the kind of problem they think they have. I recently published a book on the therapy relationship (Karnac, 2015) that compares therapy to a type of friendship, tracing a history of the common virtues that have informed writings on wise counsel, pastoral care, and the concept of a friend. I don't want to underestimate the value of theoretical ideas and techniques just so long as we realize that advising others on the problems of living is never a purely technical enterprise.
Richard Hallam trained as a clinical psychologist and has worked in a variety of UK National Health Service settings. He was heavily involved in University-based training courses for clinical psychologists. He now works in private practice and is a trustee of Daily Life Ltd, an arts and mental health charity based in London. Recent books include Virtual Selves, Real Persons (CUP, 2009), Individual Case Formulation (Elsevier, 2013), and The Therapy Relationship: A Special Kind of Friendship, Karnac Books, 2015). He also publishes books under his own imprint, Polpresa Press.
Eric Maisel, Ph.D., is the author of 40+ books, among them The Future of Mental Health, Rethinking Depression, Mastering Creative Anxiety, Life Purpose Boot Camp and The Van Gogh Blues. Write Dr. Maisel at email@example.com, visit him at http://www.ericmaisel.com, and learn more about the future of mental health movement at http://www.thefutureofmentalhealth.com
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