gwynneth COSTECALDE

As stated above, I am working on a book series called Rubble Builders. Rubble is such a harsh word, associated with war and destruction but from Rubble, the Maltese Walls were built. I discovered from a builder that the mist that forms from rubble must be dampened and clear vision of the site must be had before any work can begin. In a way, for me it's a metaphor for how CBT therapy works. The client arrives in a state of confusion and pain often unable to explain their own psychological rubble. The therapist is holding the hose that serves to diffuse the mist of difficulty, fear and anxiety, so that collaboratively, client and therapist can work on identifying the Why and move on to tools that will help the client understand how to reduce the anxiety and depression. I relate to the idea that out of something ugly can something beautiful be built. I know some people have no idea what to expect and are understandably nervous when they meet the therapist for the first time, so I always spend time initially psycho educating as to the 5 part model - explaining the vicious circle that involves feelings and bodily reactions, behaviours and thoughts relating to a given situation. I find this is a good simple way to introduce the concept of hope, a sense of gaining control over what is happening in the mind, right at the beginning. The first few sessions really involve information gathering about the client's current problems and background. This is necessary in order to be able to build a strong Case Formulation. I explain it to the client as their own personal jigsaw, the pieces of which we start to put together collaboratively. The sharing of this Formulation can often be emotional for the client, as patterns are identified and understanding gained. It paves the way for the tools and treatment in future sessions. I love refining and checking this Case Formulation after every session. During this time and underpinning the questioning is the hope that the Alliance between client and therapist develops and that the seeds of trust and honest collaboration start to grow. I know that this therapeutic Alliance is vital in relation to achieving the appropriate therapeutic goals . I am to work empathically and it is always a joy to see a client relax into deep trust . I would never wish to keep a client where the alliance was weak, for their sake. Throughout all sessions I consciously use Socratic Questioning to draw out my client. This helps to avoid "telling" and encourages the client towards guided discovery . This helps them to feel very much part of the solution, involved and participating in active therapy. I discovered how powerful a tool it is many times and I think of my client with Panic Disorder who feared dying from a heart attack and was recounting how many times he was experiencing these attacks. I asked him quietly how many times he had died and there was silence and then very quietly he said . "I haven't died". The act of saying so was very powerful for this client. While I love the structure of CBT and have seen how effective it can be with certain disorders I am aware that it is not appropriate for every client and I have learned how to integrate ACT and breath work particularly with clients who suffer from long term chronic health conditions or cancer. Here I lean on the value aspect of ACT in situations that can not be changed. I also never refer to session bridging work as homework . I don't like the schoolish association and I tend to encourage any exercise that is done outside of session as the client experiencing therapy independently thus reinforcing the practical goal orientated side of therapy - talking with purpose. Learning how and when to integrate is a skill I am still learning but I am increasingly becoming more confident. I consider the end of therapy to be as vital as the beginning and preparing the client to leave takes a little time and I need to be confident of their readiness and ability to cope independently , that they have mastered the tools that will come to their aid when access to the therapist has ended. .