CASE STUDIES; Cognitive-Behaviorism Comes of Age: Grounding Symptomatic Treatment in an Existential Approach

Article excerpt

Cognitive-behavioral therapists are still often dismissed as simplistic, shallow and reductionistic by clinicians who know nothing about it except what they vaguely recall about rats running mazes from undergraduate psychology classes long ago. According to common caricature, we reduce all human distress to superficial, bite-size behavioral symptoms and maladaptive thinking habits, then apply standardized techniques to train people, rat-like, into acquiring new behaviors and new thoughts. Many concede that this primitive kind of intervention is all well and good with straightforward phobias and simple anxieties. But we are frequently accused of ignoring the "deeper" layers of human experience, and told that our blinkered method makes it virtually impossible for us even to form a resonant therapeutic alliance, much less help people deal with "serious" issues like trauma, grief and loss, troubled relationships or the meaning of life and suffering.

While there was some truth to this cramped and narrow vision of cognitive-behavioral therapy 30 years ago, it severely misrepresents the way we work today. Now, we begin with the assumption that people do not come to a therapist because they experience "errors in thinking," but because they feel bad. To sidestep emotion would seriously undercut our ability to help people deal with the cognitive distortions that keep them stuck in self-perpetuating cycles of misery and incapacity. So, while we don't dwell on emotions at great length in therapy, or speculate endlessly about their causes, we believe it is critical for people to face, experience and accept their feelings of loss, fear, anger and grief--particularly in the aftermath of trauma.

More important than just "getting in touch" with their feelings, however, traumatized clients often need to readjust their entire relationship to a world that suddenly seems starkly frightening, chaotic and out of control. Unlike cognitive-behavioral therapists of three decades ago, we direct much of our effort to helping clients make a deep existential shift--to a new understanding of the world. At the same time, we try to remain true to our roots in a method that is practical, systemic, concrete, brief and rigorous. Along with helping clients face squarely the inescapable reality of grief and pain, we address their specific symptoms and give them the tools to live fully even in the hard knowledge that life is always a gamble. The direction of therapy is more forward into the future than backward into the past.

A False Sense of Control

My work with Celeste illustrates this integration of existential and trauma-focused approaches with classic cognitive-behavioral methods. Celeste was a veteran international flight attendant referred to me by her airline's Employee Assistance Program because she was having disabling panic attacks. With tears in her eyes, she related a story of trauma that has tragically become all too relevant given the devastating events of September 11.

For more than 30 years, she had flown regularly to Europe and had always loved her work. A few months earlier, however, Celeste had asked a fellow flight attendant to switch flights so that she could attend a family reunion. The other attendant--a bright, young rookie who had just gotten engaged--agreed. On the day of the reunion, the jet liner exploded in a ball of fire only minutes after takeoff, killing several hundred passengers and close to 30 crew members, including Celeste's friend.

Celeste was devastated, as were many in her industry. She found herself haunted by the thought that she had caused the death of her coworker, who had been her daughter's age. She repeatedly told herself and her family, "I was supposed to die on that flight. That was my intended fate. Death is not easily cheated, and I cheated it at the expense of someone else."

This ferocious regime of self-recrimination fueled a runaway train of obsession, difficulty eating and sleeplessness. …

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