10 COGNITIVE THERAPY IN CLINICAL PRACTICE

much I really do and get pleasure out of. It is a simple exercise but it might help me to start to appreciate more (75%)

* See Bums 1980.

It was considered premature in this case to discuss perfectionist attitudes at this point and appropriate to start monitoring and challenging automatic thoughts in a systematic way. The patient’s perfectionist attitude appeared more basic than the ‘I should do something useful at all times’ discussed earlier. Challenging basic attitudes at an early point in therapy may alienate the patient and make her feel threatened and insecure. Towards the end of treatment, the therapeutic bond is stronger and often the attitude has been weakened by dealing with the automatic thoughts which it fosters.

An explanation followed about how to fill in the dysfunctional thought forms. These forms were not used earlier on, because the assignments were primarily behavioural or related directly to rehearsing what we had discussed in the sessions. At this point, Anne understood the process of CT well. Her mood was better, though fluctuating. Her sleep was still disturbed in the morning and her only medication was still amylobarbitone 60 mg nocte.

Assignment Thought forms and distraction in the morning (reading and talking to nurses).

Sessions 7–26

These sessions continued mostly on a daily basis, with breaks at the weekend when the patient often spent time at home. Special behavioural assignments were set up during these weekend breaks. A great deal of time was spent on discussion of the daily records of thoughts which Anne filled in diligently. At first, the rational column was completed in the session and later Anne could do the modifying of the automatic thoughts herself. Table 1.1 gives examples which are extracted from several of the forms which were completed on carbonised sheets, so that both patient and therapist could keep copies for their files.

Anne had become very proficient at challenging her automatic thoughts, as she could remember the discussion we had in the sessions and could reproduce appropriate responses which she found elevated her mood on the whole. She had started reading Feeling Good (Burns 1980) and enjoyed re-reading certain parts of the book which she felt applied to her.

Dysfunctional attitudes These were not difficult to elicit in Anne’s case as she herself often summarised her attitudes to prompts like: ‘What does that indicate?’ We also developed a sort of game which involved underlining or repeating the words she used very often. These were ‘unfair’, ‘should’, ‘full potential’, and ‘standards’. She herself had mentioned the word (or, rather, the neologism) ‘perfectionistic’. We reviewed the themes which had emerged through the sessions and these related to being liked, to coping, and to achieving. When asked about what there was in common in the work and church situations which hurt her the most, she said: The loss of status, it’s so unfair.’

T:Yes, our discussions seem to show that. Also, you remember the words we noted that you used a lot. ‘Unfair’ was one of them and there were others: should, standard, etc. It sounds as if you have been operating under a rule which says: ‘If I work up to my full potential, I will be liked and rewarded. If I am not, either I am no good or people are being unfair.’ Does that sound right to you?

P:Yes, that’s been the trouble. It’s also because I put some people on a pedestal. It’s as if they can do no wrong. And when they do, I feel terribly disappointed.

T: Do you then feel they are letting you down personally? Do you personalise it?

P: I feel let down and insecure. I feel I can’t have faith in anybody.

T: You feel that they should not come off the pedestal you’ve put them on?

P : Laughs.

T: Did they ask to be put on a pedestal?

P: No. It’s silly, isn’t it?

T:Well, it’s not silly, but it’s not helpful. It’s as if you’re setting yourself up to be disappointed. It’s related to these high standards and expectations, isn’t it?

P: Yes. But what can I do about it? I’m too old to change now.

T:Is this true? Have you changed your ways of thinking about anything recently? It’s the same about these attitudes. You remember the work we did before on allowing yourself time to relax without feeling guilty?

P: Yes, I’m much better at that now. I plan my time better and I don’t feel bad about it.

T:That’s good. It means that change is possible, isn’t it? You told me that you’ve been reading the chapter in Feeling Good about perfectionism; did that help?

P: Yes, quite a lot.