Cognitive self-therapy: a contribution to long-term treatment of depression and anxiety

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In the eighties Peter den Boer did his CCI teacher training with John Heron and Roy Brussé. He completed his studies in medicine and psychiatry at that time as well.

As a resident-psychiatrist, he observed problems among psychiatric patients which were very similar to the problems he saw in people who were in co-counselling and other self-help groups. He was wondering whether psychiatric patients would profit from these self-help strategies as well.

Together with his partner Carla Raes he developed the “Cognitive Self-TherapyCST, also called “Experiential Self-Therapy”.

There are many similarities between CST and CCI co-counselling. In both approaches people arrange sessions in pairs. They take the roles of client and counsellor in turns with equal time in each roles. In both approaches the client is in charge. Unlike the free flow sessions often used in CCI co-counselling, his approach sports structured, step-by-step, sessions. In CCI we know something similar in the ID-Check, the 'Aware Negotiation of Sexual Attraction' (ANSA) contract or the 'Pain-to-Power' procedure. This structured session approach seemed to have made his CST suitable for patients with anxiety and depression disorders.

Peter wanted to establish the effectiveness of his self-help approach in a scientific way in order to avoid self-fulfilling prophecy of its own ideas. The attached thesis contains the various research projects for which he received his PhD.

This type of research established an evidence base for the credibility of his Cognitive Self-Therapy approach.

Why this study might be of interest to CCI Co-Counselling

Research of the Self-help Method effectiveness
Peter den Boer’s research shows that his form of co-counselling self-help can be as effective in the treatment of depression and anxiety disorders as treatment by professionals (Chapter 5).

Although CCI Co-Counselling generally does not present itself as therapy[1], it still offers ways how people can process their emotional experiences. Hence it may be worthwhile to investigate what can be learned from Peter den Boer’s approach in order to make CCI Co-Counselling more effective.

At the same time his thesis might serve as an example of how the effectiveness of CCI Co-Counselling might be researched. If successful, CCI would gain credibility, increasing referrals from professionals, professional organisations and the many people who have learnt co-counselling in the past.

Self-help Cost-effectiveness research
In the second part of his thesis Peter den Boer presents an evidence-based case of the economic advantages of self-help therapy compared with the equally effective therapy provided by highly trained professionals.(Chapter 6). In cash-strapped times, this is a very powerful argument to get referrals from mental health and other professional organisations.

Future development of Co-Counselling Theory and Practice
Peter den Boer was originally trained as a CCI Co-Counselling teacher by John Heron and Roy Brussé. However, he took the development and research of his approach of Co-Counselling outside CCI. John Heron originally (1996) proposed his Co-Creation approach outside CCI. Could these cases imply that Co-Counselling theory and practice cannot really be developed from within CCI?

If so, how can we create a better space within CCI for evidence-based development and improvement of co-counselling theory and practice?

Perhaps we can learn here something from the Open-Source software community. In the first place their software is transparent, free and can be used by everyone the way they want, including improving and changing it. The hope and practice is that if someone makes improvements they offer these back to the original developer and community at large. By doing so the quality of the software increases. This results in a win-win situation for everybody.

They make also their software usable in an as wide a range of situations as possible . For this they often use the distinction between the 'core' program (used in all situations) and add-ons that make the software functional for use in specific situations. The more diverse the add-ons are, the more relevant the software as a whole becomes for a wider range of people.

How can we use these ideas from the Open Source Community for developing Co-Counselling theory and practice?The idea of Core and Add-ons might form a framework for people contributing back to the CCI community.

In Co-Counselling the ‘core’ is likely to be the Session: the client is in charge of the session exploring his or her own emotional truth and reality with the support of (but not in a conversation with) the counsellor. This takes place on a reciprocal basis.

In a Session Contract the client and the counsellor clarify and negotiate what they can expect from each other. The Core session contract is the ‘Free Attention’ contract. From the counsellor the Client can expect Free Attention’ leaving the client in charge of the session, and time-keeping. The counsellor in turn can expect the client to be self-directed and to maintain their balance of attention while not trying to engage the counsellor in a conversation or asking for advice.

All other session contracts and session procedures like the ID-check can then be seen as ‘Add-ons’ to this core Free Attention Contract. The client clarifies and negotiates what kind of extra support or suggestions on top of the core Free Attention contract might be needed from the counsellor. Whatever contract is agreed the client stays in charge of the session.

The wider the range of the ‘Add-on’ contracts is, the wider the relevance of co-counselling for the various life situations. Some session contracts and procedures are more functional for processing restimulations, some are more functional for designing a life and a future (life action), while other contracts are good in supporting people to work on depressions and anxiety. Here is where Peter den Boer’s structured sessions or John Heron’s co-creation contracts might have come in…

Contents of the thesis

Chapter 1 - Introduction

Chapter 2 - Why is self-help neglected in treatment of emotional disorders by the formal health-care system?

Chapter 3 - Paraprofessionals for anxiety and depressive disorders

JP: This chapter is a literature review of research so far into the effectiveness is of any kind of psychological treatment for anxiety and depressive disorders performed by ‘paraprofessionals’.

JP: ‘Paraprofessional’ has two meanings:

  • a trained worker who is not a member of a profession but who assists a professional, like a dental-hygienist assisting a dentist. In Peter den Boer’s thesis the term 'paraprofessional' refers also to the teacher who is trained to teach the client and counsellor skills to lay-people. The in this way trained co-counsellor is in turn the 'paraprofessional' who supports the client.
  • The ‘paraprofessional’ is not necessarily a person, it can also be a professionally supported self-help book supporting the clinet to be in charge of his or her session.

Chapter 4 - Cognitive Self Therapy CST

JP: An evidence-based study investigating the effectiveness of the self-help therapy developed by Peter den Boer and his associates.

Chapter 5 - Cognitive Self Therapy for chronic depression and anxiety

JP: An evidence-based study comparing the effectiveness of CST for the treatment of chronic depression and anxiety with therapy when a therapist is involved.

Chapter 6 - Cost-effectiveness of cognitive self-therapy for depression and anxiety disorders

JP: compared with the usual therapy when a therapist is involved. This chapter makes the economic case for his self-help based approach.

Chapter 7 - Discussion

Chapter 8 - Summary/Samenvatting

Appendix


[1] In the USA CCI co-counselling actively denies to be therapy and in Germany (Münster) the 'Haus Kloppenburg' Therapy Centre has integrated co-counselling as self-help supporting the professional therapy it provides.

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