CBT Skills Training for Hypnotherapists

Quick links:
→ Introduction
→ Qualification Level
→ Syllabus
→ Verification and teaching
→ Fees / Dates
→ Review by John Crawford
→ A Welcome letter from Chris Mattravers, Senior Lecturer
→ Application Form

Introduction

a) Provide a nationally accredited CBT qualification suitable for and relevant to hypnotherapists.

b) Provide CBT skills, both practical and academic, which will give supportive structures for use in the consulting room.

Everyone in practice will have already appreciated that the NHS, on the advice of NICE, has moved almost overnight to promoting CBT as the ‘talking therapy’. Quite rightly it is incumbent upon members of our profession to have a good understanding of CBT and, if we wish to work alongside the medical profession, proper accreditation.

The CBT course at the Clifton Practice consists of 50 guided learning hours plus extra murals over a three month period including three weekend attendances at the Clifton Practice.

Qualification Level

Syllabus

Unit 1 - Understanding Professional Issues
Unit 2 - Assessing the Needs of the Client
Unit 3 - Therapeutic History and Methodology
Unit 4 – Treating the Client

CBT Course Programme

Day 1
Module 1	CBT in Context
1.1	Course Overview
1.2	History and background of CBT
1.3	Philosophical Considerations
	Positivism & Humanism
	Epictetus, Socrates & Philosophers
	Noumena & Phenomena (Kant)
	Elegant Solution
1.5	Current and future therapies developed from CBT.
11.1	Research Underpinning CBH (Module 11 CBH)
Module 2	Clinical Considerations
2.1	Premorbid personality
2.2	Severity of Illness
2.3	Therapist Limitations
2.4	Ethical Issues
2.5	Relationship between Anxiety & Depression
2.6	Anxiety
2.7	Depression
Module 3	CBT Concepts
3.1	Limits and Contra-indications of CBT
3.2	Three Systems
3.3	Locus of Control
3.4	Ellis’ 4 Insights
3.5	Suitcase Model
3.6	Cognitive Errors (Beck) Cognitive Distortions Negative Triad Schema
3.7	Irrational Beliefs, Categorical & Flexible Thinking
3.8	Cognitive Model of Depression
3.9	Cognitive Model of Panic attack
3.10	Stress Vulnerability Model
Day 2
2.8	Anger, Addictions & PTSD (Module 2. Clinical Considerations)
1.4	Compare CBT with Solution Focused Brief Therapy (SFBT) (Module 1. CBT in Context)
7.1	Activity Scheduling (Module 7. Using Behavioural Srategies)
Module 5	Assessment & Formulation
5.1	Collaborative Process
5.2	Trigger Factors (Current Precipitants)
5.3	Contributory Life Events (Past Predisposing factors)
5.4	Relapse Signature
5.5	Clients’ Beliefs about themselves or Problem
5.6	Maintenance cycles/Avoidance
5.7	Positive Actions (Behaviours & Thoughts)
5.8	Symptom & problem Identification.
5.9	Writing a simple formulation
5.10	Problem List
Day 3
Module 6	Client Resistance
6.1	Ellis & Rowe
6.2	Discomfort Tolerance
6.3	Tackling Resistance
6.4	Hynotherapeutic Methods
Module 4	Sessional Considerations
4.1	Time & Client Commitment
4.2	Goal Setting
4.3	Agenda Setting
4.4	Psycho-education
4.5	Homework
4.6	Scientific constructs Evidence Based practice Hypothesis Testing Use of Measuring Tools E.g. Anxiety, Depression, Quality of Life Scales, Irrational Thinking
Module 7	Using Behavioural Strategies
7.2	Exposure & Graded Task Exposure
7.3	Systematic desensitization
7.4	SMART Goal setting
7.5	Behavioural Experimentation
7.6	Excesses & deficits
7.7	Absorbing Activities
7.8	Social Skills (Communication) Training
Day 4
Module 8	CBT Strategies
8.1	Thought Records & Written Word
8.2	Situation, Mood & Thoughts
8.3	Automatic & Negative Automatic Thinking
8.4	Using Thought Records
8.5	Rational Alternative Thinking
8.6	Point & Counterpoint
10.6	Mindfulness (Module 10. Cognitive Strategies)
10.7	Cost-benefit Analysis (Module 10. Cognitive Strategies)
Day 5
Module 9	Dysfunctional Assumptions and Core Beliefs
9.1	Dysfunctional assumptions (identifying and challenging)
9.2	NAT;s, Assumptions & beliefs
9.3	Irrational Thoughts Scale
9.4	Identifying Core Beliefs through Thought Records
9.5	Laddering (Downward Arrow Technique)
9.6	Quick NLP Techniques for eliciting beliefs and assumptions
9.7	Challenging Core Beliefs (Socratic Questions)
9.8	Mind Over Mood – Challenging Core Beliefs
Module 10	Cognitive Strategies
10.1	Language & Flexible Thinking
10.2	Thought Counting & Thought Catching
10.3	Verbal Reattribution
10.4	Affirmations
10.5	Countering
10.6	Mindfulness
10.7	Cognitive Defusion (Objectifying)
10.7	Cost-benefit Analysis
10.8	Active Disputation
10.9	Distraction
10.10	Diary Usage
10.11	Assertion
Day 6
Module 11	Cognitive Behaviour Hypnotherapy (CBH)
11.2	CBT and Hypnotherapy working together
11.3	Using Hypnotherapeutic techniques to support CBT
11.4	Using CBT to support trance-work
11.5	Developing a Model of CBH
11.6	Relaxation, Lower Arousal, the Intellectual Mind
11.7	Anchoring and Post Hypnotic Suggestions
11.8	Cognitive Restructuring in Trance
11.9	Expanding Awareness & Positive Amplification

The NCFE CBT Accreditation Submission Form (for Level IV) is available. Please ask us if you would like a copy of the document.

Verification and Teaching

External Verification is by NCFE – a national awarding body. NCFE is recognised by the qualifications regulators for England, Wales and Northern Ireland. The regulators are the office of Qualifications and Examinations Regulator (Ofqual) in England, the Department for Children, Education, Lifelong Learning and Skills (DCELLS) in Wales, and the Council for Curriculum, Examination and Assessment (CCEA) in Northern Ireland.

Most of the teaching is done by Chris Mattravers and Paula Rose. The course has the enormous practical advantage of taking place at the Clifton Practice, a working clinic.

Chris Mattravers has over twenty years experience as a psychiatric nurse including eleven years in managerial capacity. His present role as Team Leader North Glamorgan NHS Trust is a 50/50 split of managerial and clinical work. He studied CBT as part of an MSc course at United Medical and Dental School, University of London. Recently completed a Post- Graduate Certificate in Business Administration, MBA course UCWN. Chris trained in Hypnotherapy at CPHT and has the award HPD (Level IV). For twelve years he has successfully used CBT with a variety of clients individually and for the last four years has provided group work for clients with depression and anxiety. Chris is popularly and properly recognised as a very good teacher.

Paula Rose has until relatively recently been a trainer in Health Education after a career as a registered psychiatric nurse. Her CV includes developing and delivering the training programme for staff at the University Hospital for Wales. She has CSCT Diploma in counselling and a post-graduate diploma in CBT. In 2005 Paula trained at CPHT and was awarded the HPD. Subsequently she has become a lecture on the HPD programme and is the CBT Assessor. Paula, in addition to her teaching roles has a flourishing practice in Wales.

CBT Fees / Dates

To be posted shortly.

CBT Training at the Clifton Practice - Review by John Crawford - Dec 2008

For those of us who know David Newton well, we may well have been secretly relieved that he himself was not in attendance for the majority of the course, as we spent six full days focusing not on solutions, but rather enthusiastically on problems! Actually, I couldn’t help but feel a sense of admiration for David’s willingness to welcome this training to the Clifton Practice, knowing full well no doubt, that it might initially seem at odds with our solution focused approach. In reflecting on the course I wanted to share my own conclusions about how these seemingly disparate therapies could complement each other and a sense of the ease with which this new information can be integrated without conflict.

Whilst nobody could disagree that Solution Focused principles remain front and center to everything we do as therapists, the CBT course gave us a clear and definitive answer to a central question. That question: “HOW….do I teach my clients to think positively?”

Every student/graduate of Clifton Practice Training will be thoroughly indoctrinated with the understanding that clients need to “Get positive and stay focused on solutions”. Many clients can meaningfully interpret this counsel and make short work of improving their mental and emotional environment by applying the “get positive” principle. In practice however, we also frequently reach an impasse with clients who are prone to being plagued by negative thoughts as part of their symptom patterns. This is common amongst our clients. They tell us “I am trying to be positive but I am overwhelmed”. For some of those clients being told that they need to “think positively” is about as meaningful (and frustrating), as Devin Hastings put it, as asking them to “flap their wings and fly to the moon”. Now that statement is unfair when applied out of context to what we as CP trained practitioners do. In fact, we don’t ONLY tell people to “think positively”. We spend our time applying powerful therapeutic tools to build and maintain positive perspectives within our clients whilst helping them with the practical business of getting their lives back on track. Even so, every therapist in practice will encounter clients whose core belief systems are so powerfully negatively focused that they simply cannot (or will not) cultivate a positive focus no matter how much you remind them, in hypnosis or out of hypnosis, that it is essential for solution. If we are inexperienced we might decide that they are a “difficult” client. Perhaps they are not willing to put the work in? Perhaps not listening? Perhaps……

But, it can be just as likely that we’re not being specific enough.

One thing I’ve learned over the years is that it pays not to assume that because something looks like common sense to you as the therapist, that it is therefore naturally understood by the client. It may be obvious to you that this client is continuing to be negative, but it may not be to them! Some things really do need to be spelled out. CBT gives us the tools to do just that, and it does it in such a way that it cannot be construed as advice or your opinion (which could of course be easily disregarded). CBT is an evidence based therapy and the facts (which we’ll get to in a bit) speak for themselves. It is therefore truly effective when it comes to bypassing client “resistance”, since it’s a therapy much less about us as therapists, or our therapeutic relationship with our clients, and much more about a clients willingness to challenge the negativity that they themselves have defined under your guidance. It dovetails beautifully with our own way of working. Since we are always reminding clients that negativity creates anxiety, it is extremely useful to be able to identify specifically what negativity you are referring to. As far as CBT is concerned, that negativity is often to be found in the structure and wording of the thoughts/perceptions themselves. When these negative thinking styles are clearly identified then we can then provide our clients with everyday tools to help replace that negativity with something more useful. Rather than just advising people to be more positive, with CBT we actually identify the problem thinking and define the action to be taken. This can be the missing key for those clients for whom positive thinking remains a mystery.

The Course
I may at some point have met Chris Mattravers and Paula Rose prior to the course but if I had it was only in passing at supervision or some similar event. It was a pleasant surprise then to find two of our own “graduates” talking a talk which was as knowledgeable at least, as any other professional training I have ever received. It was quickly clear that these guys knew their stuff. It transpires that they have both been providing mental health care for many years at the sharp end of the NHS and private caring spectrum. I certainly felt immediately comfortable and supported in their presence. I knew we were in good hands, and that fact became clearer as the course unfolded. Chris is a big presence with a Welsh valleys accent and clearly a big heart to match. Paula is less assuming, but quietly omniscient. Together, they made for interesting viewing. As if they needed to point out that they were like an unlikely old married couple, their obvious deep respect for each other was occasionally superceded by a light hearted revelation of the others foibles. It was warm hearted stuff though, and it revealed something of the intense behind-the-scenes cabin fever that had preceded our gathering.

For me, and indeed many of the attendees, CBT was not a completely new concept. The basic premise that distorted thinking creates or sustains emotional disturbance is easy enough to understand. The first weekend focused largely on clarifying this understanding. Initially I felt a little impatient with the level of attention that was being given to this seemingly simple conclusion. I understood the premise well enough. I was eager to get on and learn how to apply CBT in practice. Nonetheless, with hindsight I have found myself very grateful to have learned something more of the background of CBT as was covered in that first weekend. Understanding the important historical contributions of Epictetus, Buddha, Immanuel Kant and Albert Ellis (amongst others) has been of much greater use than I had originally supposed. In practice, being able to recount the story of Epictetus as a metaphor for how there are some things that we cannot change (particularly other people!) has proven very useful. I have become especially fond of this story because it reminds us so clearly that CBT is not a moral therapy. CBT is much less about what’s right or wrong than it is about what’s smart or not smart. Epictetus was a Turkish slave with a sadistic “master”. During a torturous leg-twisting session, Epictetus warned his master “Master, if you continue to twist my leg in this way, it will break. I will become lame and unable to work”. Nonetheless the sadist continued and snapped his leg (Duh!). Epictetus later won his freedom and opened a school of philosophy where he taught that there are some things we are powerless to change, in particular, how other people behave! He went on to explain that despite this, the one thing that we absolutely DO have some control over is how we react or respond to those events. Coming from a man who had his leg sadistically snapped this carries some weight. What is so wonderfully demonstrative about this story is that we can all see that it wasn’t “right”, either logically or morally, that the master behaved in this way, but Epictetus recognised that there was no use in adding further injury by becoming obsessed and angered by the event. Despite his obvious logical protestations, the matter was otherwise pretty much out of his control.

He concluded: “Some things are up to us and some things are not. Our opinions are up to us, and our impulses, desires, aversions - in short, whatever is our own doing. Our bodies are not up to us, nor are our possessions, our reputations….that is, whatever is not our own doing”.

Moving on, it was valuable then to learn a bit more about some of the technical clinical terms used in CBT and clinical psychology. Never having given it much thought I might have supposed that a pre-morbid personality was someone with 70’s brown and green paisley wallpaper and a bad dress sense! Of course, when explained it refers to a persons personality “before the development of illness”. It makes perfect sense to be taking account of this when assessing a person’s recovery expectations. Whilst it’s important to create a positive expectation for clients, it’s equally important for that expectation to be realistic. To expect someone who has suffered with long term (lifetime) depression to become filled to the core of their being with sunshine and light in six sessions is generally unrealistic. Apart from the fact that you risk mutual disappointment (accompanied by a sense of “failure”) when that expectation is not fulfilled, such an expectation can place too much pressure on both therapist and client alike. Following this understanding we were naturally led to examine why some personalities will heal more quickly and thoroughly than others. What we at CPT may call a “template” or “precedent”, CBT might call “schema”. Again, avoiding the moral implications of “right” or “wrong”, “good, or “bad”, CBT instead uses the terms “adaptive” and “maladaptive”. Adaptive means functional/helpful, maladaptive means dysfunctional/unhelpful. The term “Early Maladaptive Schema” therefore refers in short to ways in which an individual has learned (usually in early life) to relate unhelpfully to the World, Self and Others. World, Self, and Others incidentally are referred to in CBT as the Cognitive Triad (“The three perceptions” - my words). Schema are essentially perceptive filters that sort our incoming information into meaningful experience. Schema can be summarised as “what we make of things”. My schema will decide for me whether that person who is staring at me from across the road is admiring my jeans or looking for a fight! Obviously, if my maladaptive schema decides that the latter is the case, I will in the best case feel stressed or angry and in the worst case end up in hospital. Schema, clearly are important. For people who have had a lifetime of seeing the world, self, and others negatively, we are going to need to do some serious salesmanship to convince them otherwise. Selling the idea that things may not be what they seem requires evidence. Here is where CBT excels, because evidence is exactly what it provides, albeit still under the skillful guidance of a positive practitioner.

We looked at the varying severity of illness and how to assess suitability for CBT intervention, acknowledging that in the throes of an emotional storm it may be difficult for some clients to focus enough to use the structured approach offered by CBT (enter hypnotherapy!) The assessment procedure for CBT is nicely clinically structured and focuses on making a succinct one page “formulation” which contains everything you need to know about your client’s basic history, difficulty, and potential resolutions. Whilst this remains an obviously effective process I have to say that being a creature of habit (who isn’t?) I am so used to my own consultation procedure by now that I didn’t personally adopt the CBT formulation procedure; but I could see value in it nonetheless. If you were using pure CBT the formulation would be central to the process since it looks at clarifying the treatment plan. For me anyhow, the Miracle Question and similar approaches serve the same purpose.

Our second and third weekends moved on to the practical application of CBT in the consulting room. The pace was largely good. A few areas were skimmed over but the sheer volume of information in the course made this somewhat inevitable. I was aware throughout the course that it was too much to fully digest in one sitting, but the learning has been in revisiting the material (an ongoing process) and slowly integrating it into my everyday practice. Despite the fast pace Chris and Paula did make sure that each point of focus was properly understood before moving on.

In reflecting on the content of the course I’ll spare you the boredom of a data dump and get straight to how it’s been useful. No doubt, my experience of using the techniques will differ widely from others, so this is by no means an exhaustive description of possible uses. These techniques are a flexible mix and match palette that could be used quite imaginatively in a wide variety of situations. I’m still finding new uses all the time but here are a few of the core tricks I’ve learned.

Firstly, I have printed handouts of the basic principles of CBT as suggested by Albert Ellis, known as Ellis’ Insights, which I now give out as standard to pretty much every client. These (shortened) principles are as follows:

• Insight 1 – How you feel is mainly determined by the way you think.
• Insight 2 – You become distressed when you endorse your own irrational beliefs.
• Insight 3 – Be kind to yourself. You, like many people, can think irrationally so don’t judge yourself too harshly.
• Insight 4 – You have to make a sustained effort to recognise and challenge your irrational thoughts.

Irrational Beliefs. An example: -

Recently I met a lady who told me that she “believed” that during a flight she feels personally responsible for holding the aero plane up in the air with her mind. She said “I know that’s crazy….sort of…..but I still believe it”. I did of course remind her in my gently diplomatic manner that the idea was completely ridiculous. She remained nonetheless attached to this belief, presumably because she perceived it was her only way of maintaining any sense of control. When you’ve been around the block a few times, you come to expect this in practice. So with a quick spin of the revolving doors……Enter CBT Man! I explained the principle of how we can become emotionally disturbed by endorsing irrational disturbing thoughts, and whipped out a trusty “cost to benefit analysis” sheet. This is basically a two column sheet which asks the client to list the benefits versus the cost of a particular decision. In this case the decision was to “hold” or “let go of” this belief system. There is the risk of course of infantalising your client with a trick like this, and it wouldn’t be good practice to use this in every situation, but with a belief this irrational, one has to ask whether the client has already infantalised themselves? In a subtle way, having to work at such a mundane level just highlights the ridiculousness of the belief. If that’s the level you need to work at then it’s a fair cop! So we spent ten minutes exploring what the cost of holding a belief like this would be and what the benefit might be of letting it go. Since she was in for aerophobia she quickly came to the conclusion that solving her flying anxiety would involve choosing to release that belief. All in a days work for us perhaps, but it was a minor Eureka moment for her. I was then able to hand her the sheet we had just completed and let her take it home with her. This lady was a particularly difficult case. I had to be rather blunt and ask her if she was taking the therapy seriously. It then transpired that she had until this point intended NOT to do any of the work herself. In her own words she told me that she now recognised her expectation had been unrealistic and that she wanted me to just “fix it”. I may well have been able to succeed with this lady with just a rewind and a reframe, but this simple bit of CBT work meant that she was no longer in a position where she could simply blame the therapist if it didn’t work, which was essentially, she confessed, her unconscious plan from the outset. We took an extra session in the end which I gave her free of charge, and eventually we succeeded whilst helping her with a lot more than just her flying fear. Challenging, but rewarding! The beauty of this simple technique, like so many in CBT, is that we have a tool to get the client to arrive at their own conclusions by asking the right questions. This means that we’re not giving our opinion or advice. Instead we are inviting our clients to think clearly. Implicit in this also is the unspoken recognition that the “rules” are not ours (the therapists) but life’s rules. It sweetens the medicine for Warriors who don’t want to be “told” what needs to happen, and it makes acceptance of the facts an easier pill to swallow. They are pleased to feel they figured it out for themselves. I know that for us, this way of working is not particularly exciting or profound, but as I said earlier, you are wise not to assume that just because something is obvious to you as the practitioner that it is necessarily so obvious to your client. So, now having established a willingness to challenge the irrational belief we then came to the question of how to change the belief?

Here we used the “Thought Record” format. Basically here we look at the “belief” along with its associated thinking and look at the evidence for and against the assumptions that we find there. Having looked at the “evidence” for whether we do in fact “hold planes up with our minds”, and thoughts such as “If I don’t maintain control all these people will die!” we then looked at creating alternative balanced thoughts. In this particular example, this was easy to do. We wrote in that column: -

“Pilots fly planes, not passengers... Pilots are professionals who can be trusted to fly planes safely... I can relax…Flying the plane is not my responsibility. I KNOW that feeling responsible for the flight or the passengers on the flight is a false positive signal that causes me to feel unnecessarily stressed and fearful. There is NO evidence that those perceptions have any basis in fact. They are just feelings. Feelings are not always facts. I CAN choose to relax and the flight will arrive safely. I choose to relax….. Etc”

Armed with this new understanding, my client was able to “adjust” her negative perceptions with a more rational factual perspective, thus eliminating any possibility of an insidious post hypnotic fear re-infection. I was then able to get on with the hypno-job in hand.

Language Structures
The world is made of language. At least, our personal worlds are made of language. We colour and flavour our world view with the language that we use.

The idea that imperatives such as “should, have-to, ought to, must, etc” could be a source of mental and emotional disturbance was not new to me. “Stop “shoulding” all over yourself” was a useful phrase that stuck in my mind many years ago. This idea was made all the more user-friendly however in the CBT course with a page of statements such as:

“I must be accepted and liked for everything I do by everyone who is important to me”. Agree/Disagree?

“If someone asks me to do something for him or her in a nice reasonable manner, then I should say yes and do it” Agree/Disagree?

It is a wonderful tool to use with clients. You can simply ask them to ring “agree” or “disagree” to each statement. It takes about 30 seconds to have them complete this task and their answers tell you an awful lot about their thinking and belief structures. Shockingly, many people will return a page full of statements marked “Agree”. You immediately have an insight into the source of much of this persons stress. Take our first statement here for example. “I must be accepted and liked for everything I do by everyone who is important to me”. Agree/Disagree? Is it reasonable to expect to be liked and accepted for everything you do by all the people who are important to you? A person who believes it IS reasonable or worse essential, is going to find themselves with a great deal of internal conflict if their Mother doesn’t approve of their new choice of partner……or doesn’t like their haircut... or... well... any “choice” they make!

When the discomfort of being unaccepted becomes too great to bear (known in CBT as Low Frustration Tolerance), our client becomes paralysed for fear of making a choice that will cause such rejection. Therapeutically we can get straight to work on helping this person to understand clearly that:

a) Their mother will probably love them whatever they do.
b) They might have it wrong! Perhaps their Mother cares less than they think she does about their decisions.
c) If their Mother did reject them for a decision, then that is their Mothers problem, not theirs! (Boundary resolution work ensues!)
d) Life is too short to be spent “worrying” about what other people think.
e) Other people will adjust their position when they know that we’ll do what we want with or without their “acceptance”.
f) Not every decision can be comfortable for everyone involved. It is simply not possible to be all things to all people or to please all people all of the time. We need to get comfortable with this fact of being and learn to be comfortable with some discomfort some of the time if we are to be in control of our lives. In CBT this means raising a person’s frustration tolerance.
g) Do we stop liking or accepting people when they do things we don’t agree with or like? Etcetera!

Statement two - “If someone asks me to do something for him or her in a nice reasonable manner, then I should say yes and do it” Agree/Disagree? Here we find a person who has a problem with saying “No” to people. Immediately we learn that this person could use a quick lesson in the virtues of “constructive selfishness” and why it’s okay to say no sometimes. Sometimes hypnosis is permission. A few well worded hypnotic suggestions and metaphors here can make a world of difference for your client.

I have had a number of clients for whom this understanding of imperative self-talk was priceless. They recognised that their language structures were filled with “shoulds” and “musts”, and went about a complete re-structuring of their world views almost without any help from me. It has been quite incredible to watch people stop mid-flow whilst talking in the consulting room and adjust their language…recognising that they were about to slip into a negative imperative self talk. Of course, this follows a short period of me nagging them to listen to what they are saying (thinking), but over time I have watched people completely change the way they speak. “Cannots” become “Cans”, “Always” become “sometimes”, “Musts” become “like to/prefer to”. It goes almost without say, that when your client is speaking in non-imperative language they are also usually telling you that they are mysteriously feeling much better!

Rules
Further, an absolutely essential part of this understanding is that when we have “rules” about things generally and those rules are then contravened, the inevitable outcome is emotional disturbance. We’re here back to the Epictetus story (the slave with the broken leg we spoke about earlier). This has been an absolute gem of understanding in the consulting room. Sometimes we have to help people change their “rules”. When people change their expectations of situations and people, they can often learn to live more comfortably with eternal truths such as

• You can’t change other people. Only they can change themselves.
• Pain and pleasure pass. All things are ever changing.
• There are some things in this world we cannot control…..to name but a few!

In real terms this is an extension of the “should” understanding i.e “My wife SHOULD be more understanding of my situation.” Clearly, a change of expectation will reduce the stress when she’s not!

Thinking Distortions
Also very important and central to CBT is the understanding that people have thinking styles which can make them feel bad about the World, Self, and Others. Distorted thinking creates a negative outlook. Learning to spot and amend these thinking styles is a key skill to master both as a therapist and for your clients. A few examples are shown below, but there are many more….

All or nothing thinking
This is “absolute” thinking. Here, if something is less than perfect, then it’s seen as all bad! If we can’t do it/ have it all, then it’s not worth trying. This can create feelings of being overwhelmed. Chunking down is the process whereby we tackle things in bite-size chunks, which often makes them appear much more manageable, and recognise too that maybe we can do SOME of it if not ALL of it.

Over-generalisation
Characterised by using the words "always" or "never". Thinking this way creates feelings of being consistently defeated. It is RARELY based on FACT. To overcome over-generalisation we look for exceptions to these internal assertions.

Mental filter
This filter involves filtering out whatever doesn’t “fit” ones beliefs, and looking ONLY for evidence that supports your way of seeing things, even if that’s purely negative. Usually this means dwelling on a single negative detail and excluding all else! Extreme fundamentalism is an easily recogniseable symptom of this kind of thought distortion, and good evidence to remind us how deep it can run in some people!

Negative Forecasting
Forecasting that the future (events and general) will be awful is a massive cause of stress. Since your brain is the most powerful future experience rehearsal machine in the World, your poor old (not so logical) subconscious mind gets very worried indeed when you negatively rehearse the future as a frightening destination! When you tell yourself that things will turn our badly, you create fear and stress. Then, because you’re so stressed and fearful, your performance drops; everything turns out badly, and you say “See! I told you so!” Then whole cycle then begins again, but reinforced because it did in fact go as badly as you imagined. Ironically that’s because you imagined it going badly first!

Obviously having a good understanding of these thought distortions is important in the consulting room. We need to pull clients up on such distortions as they occur and help them to understand that they are anxiety provoking perceptions requiring amendment. CBT offers some very useful tools for unpicking such disturbing thought processes.

Socratic Questioning & Chaining
The famous Socrates was apparently an expert in critical thought. Rather than just accepting what people said he would use (sometimes initially irritating) questioning to help people to think more deeply into their assumptions and test them. He would say “How do you know that is true?” “What evidence do you have that that is so?” By extension, you then have questions such as “And if that were true what would be so bad about that? Or “If that were true what would that say about you?” These are questions designed to help a person investigate their belief’s about self world and others. Very quickly using this form of questioning you can “chain” back to the root of a negative thought or belief to discover what the “real” issue is.

If someone is telling you for example that they have a fear of being intimate with other people the conversation might follow:

“If you were intimate with people, what would be so bad about that?”
I would feel embarrassed
Because?
I don’t like to let people get too close
Because?
I’m afraid of showing who I really am.
And if you were to show who you really are what would that say about you?
They might see something they don’t like.
And if they did see something they didn’t like, what would that say about you?
It would show how flawed I am.
And what would be so bad about that?
It would mean I’m a horrible person.
And what would be so bad about that?
I couldn’t bear for anyone to know how horrible I really am.
Do you really believe you are horrible?
YES!!

Core belief: I am horrible!

And so off to work we go...

Socratic questioning also helps greatly in being able to highlight thinking distortions as described above.

Behavioural Learning
It might seem obvious to us that when someone succeeds in doing something they didn’t think they could do, then that constitutes “success”. It would be easy to assume that this “success” is naturally noted by the client also. As Zen master Roshi pointed out however…… “Not always so”. CBT formalises this process of noting successes and using them to change core beliefs about World Self and Others. Behavioural Experiments as they are called in CBT work beautifully within the principles of solution focused hypnotherapy. Basically, you have the client tell you what their expectations of a forthcoming situation are. You get them to rate their expected “fear” (or whatever emotion) using a Subjective Unit of Distress (1-10 or percentage). You then do your CBT/hypno-work on them and have them diary their experience for revision. When they come back you review their experience together, and assuming there was improvement you use that experience to set more positive future expectations. Together you literally re-write the belief system and remind them that next time they approach a similar situation they can refer to this learning to remind them of what a “realistic” expectation looks like. Over time, this helps your client to gain confidence in approaching challenging situations and ultimately teaches them that they can do the things they want to do, as well as offering evidence that their experience is often much more positive than their initial expectation. In other words it gives them confidence to stop expecting the worst, because the experiential evidence shows a different picture. Again, it is the formality of having it in writing that makes the difference. As I said, it’s easy for us to assume that it’s been noted but often when you check in with someone and say “……You do remember that you had a whole week of feeling great last week don’t you?” you discover that they had in fact discounted it!

Goal Setting
Again, by no means a new concept, but one to which I must confess personally to having been a little less than perfectly structured with. I know quite a few of our group were already familiar with the S.M.A.R.T goal setting concept, but it was new to me. Again, I enjoyed the fact that peoples limitations were taken into account. Ideally then, goals should be SMART, that is, Specific, Measurable, Achievable, Realistic, and Time-limited. We looked at the concept of splitting big goals into little steps. This is known as “chunking down” in NLP. It helps to make a goal look possible by seeing that we approach each step of the goal one bit at a time. It’s this structure that makes goal achievement seem so much more possible. Often clients are looking only at the overall picture and feeling overwhelmed. When we break it down in to small manageable chunks it starts to seem more possible. The handout sheets made this process easy to present to a client, but most of all it gave me greater confidence and clarity in being able to structure goal setting in a realistic and palatable way. Although both SFBT and CBT are goal oriented, with the CBT approach the emphasis is much more on setting specific goal tasks and then reviewing to see whether it has been achieved before moving on. Some people like this structure, others prefer a looser approach. It can be integrated according to your own personal preference but the tools are there to use, and that’s what counts.

Summary
There is more. Much more! I was asked to reflect on the course, not write a CBT course, and so reluctantly I need to curb my natural desire to write the whole book! There is a lot to take in on the CBT course. As I write it is now almost a year on since I began the CBT training and I still honestly feel like I “just” have a grip on how to use CBT really effectively. I see wondrous possibilities abound and yet I also see limitation.

“Give an infinite number of monkeys an infinite amount of time and eventually you will get the result you want”. I read that somewhere. I like that thought. The problem is we don’t have an infinite amount of time, and as we all know, time in the consulting room, and indeed in our lives, is limited. This means that we may only be able to apply our CBT sparingly. When I do get spare time, I often go back through the course notes and have a look at what else I could be using. Over this year I have scanned and built a nice little library of CBT related handouts and work sheets. Some are directly from the course notes. Some are from Mind over Mood. Many of them I have written in my own words. I have created flow charts and worksheets to explain processes so that clients have it all clear in black and white when they walk away from their sessions. Without these I’m sure the CBT practice would be less effective. Again and again, it pays not to assume your client “gets it”. Often they don’t. Clients can be overloaded. In the same way it’s taken me a year to create clarity about what I do use from the CBT course, so it must be a lot for our clients to process. Despite the seemingly simple nature of so much of the CBT work this is the limitation I speak of. Handouts and worksheets can help here by giving clients something to take away and think about. They also become useful reference points in the therapy itself, saving time in rehashing important points. Worksheets also give us an opportunity to introduce understanding that we may simply not have time to introduce in the consulting room and a well designed handout can help to establish principles that your client might not otherwise properly absorb. Even so, time remains an obstacle. It is still just one thing at a time.

Our challenge I think is to be able to practice the two therapies side by side. I think we have a major advantage by being able to use hypnotherapy alongside CBT. To choose one over the other, to my mind, is to limit our potential to help. CBT has some fantastic diagnostic tools. We can often then implement solutions quickly with hypnotherapy. What might take five or six sessions (or more really in practice) of conscious mind adjustment using CBT can often be brought home much more quickly using hypnotherapy either through the use of suggestion or by image/emotion based reframing. Core beliefs for instance can be powerfully re-written through the use of all kinds of hypnotherapeutic work. The logic follows that if you change a core belief then you solve the problem of negative automatic thinking relating to that belief. In practice this works.

The course itself provided excellent support in the form of course notes. I have been genuinely impressed with the notes. They were absolutely brilliant. They were also essential as there was so much to remember. Although I completed the course with a good understanding of the principles, it was in the reviewing that the detail came into focus properly. A number of books were suggested as additional reading. “Mind over Mood” is a fantastic little workbook and again there is more than enough in there to be going on with for a very long time. It is very practical, is filled with useable worksheets, and it contains much that you could use with your clients. There is also a practitioner’s help book that goes along with Mind over Mood with suggestions for how to use the book with your clients. The other suggested book - “The Clinical Use of Hypnosis in Cognitive Behavior Therapy: A Practitioners Casebook (Paperback) by Robin Chapman” I have to say I wasn’t impressed with. It’s worth having (what book isn’t?) but I found it dry and convoluted. I don’t mind psycho-babble if it has a point, but I found that I’d read two pages, trawling through the clinical speak to get to the point and with plain English reconstruction would conclude that the point could have been made in a single sentence! I had the distinct impression whilst reading that it was a book aimed at impressing the world of psychiatry rather than helping “on the ground” Hypnotherapists. I can’t honestly say that I found it very useful. It had some interesting facts and approaches but for me as is so often the case with these books the case studies are just “textbook” studies and rarely reflect the reality of being out in the field. As at date of writing (December 2008) it is also £51 on Amazon! I think at the time we got ours for about £30 so good luck book hunting! Chris liked it though, so you’ll have to make up your own mind about whether it’s worth the investment.

Overall, if I had any constructively critical feedback about the course, it would perhaps have been that we did spend more time than was necessary during the first weekend on the most basic understanding. I think the course could be re-structured slightly to spend no more than a day on this. We rushed at the end to accommodate that first weekend. Everyone I have spoken to about the course made the same comment. Otherwise I found the whole experience thoroughly life enriching. The post course examination was similar to the HPD in that it involved reviewing and re-writing learned understanding. The examination was not overly challenging but I personally found the process useful and it helped me to solidify my knowledge into a fully coherent overview. I know that the Clifton Practice worked hard to obtain outside accreditation for the course, and it is a boost to those of us who take the course to come away with a nationally accredited qualification. I was very impressed with the lovely presentation that the Clifton Practice made of our “exam folders” for the examiners when I came in to sign my work off. Most of us have probably noticed that there is a bit of a CBT revolution going on right now in the World of Therapy. To have a nationally accredited CBT qualification can only be a good thing for us. I personally think these are great selling points for our services. The price for the course was also I feel extremely fair and good value for money.

Considerations
You get from this course what you choose to take from it. The truth is, relatively speaking, it is a basic course, but it should give you the competence to use CBT in an effective way in the consulting room. There is enough in the course to compliment your hypnotherapy practice in whatever way you choose to use it. As with all things, the perfecting of the art comes with practice and continued study. You could therefore take just a little of what you see as useful and forget the rest. If however, you find some passion for the subject you might develop what you’ve learned and look for new ways to apply it. Like any model, once you have a solid understanding of the principles, it becomes possible to mix and match to your hearts content.

In practice your clients don’t need “complex” CBT; neither, within the context of our day to day practices, do we. The reality is that most people find it enough to get their heads around the concepts outlined above, even though really they are quite simple principles. Remember, in hypnotherapy the rule is that your hypnosis sessions should be simple enough that a twelve year old could understand them and that you shouldn’t attempt anything in hypnosis that you’re not competent to do out of hypnosis. So, here too, simplicity is desirable and effective. With an average of ten sessions per longer term client and that time being split between hypno-work and CBT you’ll have your hands pretty full with the tools you’ll gain on this course……even when you keep it simple. On the surface, the course may appear rather basic, but upon closer inspection of the course notes you’ll find many nuances of understanding awaiting your development for use. Extend your developmental understanding to a book like “Mind over Mood” and you’ll find that you have enough material to be successfully developing and using for years to come.

One of the things that will be emphasised on this course is that qualification does not make you a CBT practitioner. It makes you a hypnotherapy practitioner with some formal CBT training. The distinction is one of obvious importance when it comes to presenting your skills to the World. However, something that I have noticed in practice with alarming frequency is that many people who present for hypnotherapy treatment after supposedly having a course of CBT with qualified CBT practitioners will tell me that they have never heard of a thought record, a behavioural experiment, Ellis’ insights, or even a thought distortion!

When I ask, “So what did you do in your CBT sessions?” They report that the therapist simply told them to think positively.
I ask “Well, did your therapist teach you how to do that?”
“Not really” came one reply, “They simply told me to ping my arm with an elastic band tied around my wrist every time I had a negative thought”.
“What did you think of that?” I ask.
“I thought it was rubbish” was the reply. Quietly, I agreed.

The technique itself may be useful in context, but what shocks me is that I have genuinely met people who have had ten or more sessions of CBT who do not have even a rudimentary understanding of the principles. Now either the client wasn’t listening or there are some people out there are not doing their jobs properly. This is not to disrespect CBT or its many highly effective practitioners, but I mention it because if we are doing our jobs properly we can be proud of that fact. If you are applying CBT with your clients to the level we have spoken of here then you can be confident that you’re doing a good job! Sure, there’s always more to learn, but this course will give you all you need to complement your existing skills. Where you go from there is up to you...

I would wholeheartedly recommend the course to any hypnotherapy practitioner!

John Crawford - December 2008

A Welcome letter from Chris Mattravers, Senior Lecturer

Thank you for your enquiry about our CBT (Hyp) skills diploma course. This exciting, innovative programme is jointly administered by the NCFE and CPHT and is designated as ‘NQF Level IV’ equivalent. This six day course takes place usually one weekend per month, over three concurrent months at the Clifton Practice. All suitably qualified hypnotherapists are encouraged to apply. The next course takes place on the weekends of the 22/23 Jan, 26/27 Feb and the 26/27 March 2011.

CBT is an effective, action orientated, collaborative therapy that can be used to assist clients who experience a host of conditions including: depression, anxiety, anger, eating disorders and even irritable bowel syndrome. The National Institute of Health and Clinical Excellence (NICE) guidelines that steer government and NHS policy and practice make CBT the therapy of choice for these and other conditions. It is increasingly important that hypnotherapists have skills and knowledge pertaining to CBT and its ethical application to client care. This lively, fun and interesting course provides practitioners with enough knowledge and the confidence to apply CBT methods in their practice. This combined with hypnotherapy know-how, gives the practitioner a varied toolbox of skills which can only benefit their clients and the marketability of their practice. GPs, Consultant Psychiatrists and psychologists are more likely to refer clients if the therapist has a good working knowledge of CBT.

All participating students receive a comprehensive manual, the “Mind Over Mood” reader by Padesky and Greenberger as well as first-rate support from the team at the Clifton Practice. This popular, nationally recognised course offers incredible value for money and applicants are advised to book a place early to avoid disappointment.

Yours Sincerely,

Chris Mattravers