Greetings everyone! As a new member of the Clinical Case Conference faculty, I am joining the discussion of Caroline in midstream. I am really pleased to be part of this conference and am looking forward to some lively discussions. The similarities and differences between our various approaches to the complexities of clinical practice are intriguing.
In considering the case of Caroline and looking at her family background, I am struck by the profound impact that childhood experiences have on development and later in life. Some therapists are under the impression that cognitive-behaviorists ignore the impact of childhood experiences on adult functioning or that we refuse to address family of origin issues in the course of therapy. However, this is not the case at all (Richard Bedrosian has written an excellent book on Cognitive therapy with Family of Origin Problems). This case clearly demonstrates the importance of early experiences.
On the simplest level, if I experience my parents as not being warm, loving, and accepting, I may well assume that this is happening because I am unlovable. If I also perceive my parents as telling me (through words and actions) that I am not smart, not talented, not attractive, not good enough, etc. I may believe this and carry the view that I am deficient and unlovable into adulthood. If I do, this will have a major impact in many areas of life. This could happen if my parents do see me as deficient and unlovable and I am accurately perceiving their view of me. It also could happen if I am misinterpreting my parents words and actions. Subsequent experiences can easily reinforce this belief or can complicate the picture and Caroline reports many other experiences which seem to have contributed to her current problems.
I have only learned about Control-Mastery Theory recently and I don1t have a very firm grasp of the approach yet, but it sounds like Cognitive Therapy and Control-Mastery Theory have a lot in common on the conceptual level. My bet is that the two approaches are quite different when it comes to intervention. The initial interventions described in The Case of Caroline do not sound dramatically different from what a Cognitive therapist would do. However, we would also work to develop clear, mutually agreed upon goals for therapy. Once the goals and priorities were clear, a Cognitive Therapist would typically focus on the specific situations in which Carolines current problems occur and would try to identify the specific thoughts and feelings she experiences in those situations and we would work with Caroline to identify steps she could take between sessions to make headway towards her goals (often referred to as homework assignments). It is not that we would ignore Carolines tests of us or the interpersonal complexities of therapy but we would be more focused on helping her make concrete changes in daily life.
I wonder what impact this difference in emphasis would have on the way in which therapy unfolds... In theory, we would expect it to make the therapeutic relationship less intense and complex and would expect that our focus on events occurring outside of therapy would make it easier to achieve symptomatic relief relatively early in therapy. However, this would also mean that the deep issues might well be less obvious and probably would be slower to emerge in therapy. Cognitive therapists often end up needing to actively work to identify and uncover the deep issues (which we refer to as dysfunctional beliefs or schemas) rather than having them emerge spontaneously in the therapeutic relationship. It is not that transference is unheard of in Cognitive Therapy, but it seems to happen less frequently and intensely.
Does anyone have an image of how Caroline would respond to a concrete, problem-focused approach?