on 15 February 2011
Paul Blenkiron's Stories and Analogies in Cognitive Behaviour Therapy is an excellent, stimulating book and a delightful one to read.
Anyone expecting another dry, medicalised tome will be pleasantly surprised. Blenkiron approaches his subject with clarity, humanity and even, at times, humour. Although Blenkiron's target audience are clinicians, I feel that, with a bit of interpretation on the behalf of the reader, this book could also serve quite well as a self-help manual. Refreshingly jargon free, this book is readily accessible to a wide readership. Throughout, Blenkiron's tone is straightforward never patronising or pompous. He doesn't "talk down" to his readers, but instead engages them in a lively discourse on the benefits of using stories etc within CBT. They can even be used to ascertain if a person would benefit from CBT and are an essential part of tracking change and progress within the therapy.
The term "story" is often used in mental health as, to my mind, an inappropriate and dismissive way of referring to someone's life experiences and medical history. However, Blenkiron places the term story in its true context as a tale to be told for the purposes of entertaining, explaining a situation, elucidating meaning, to enable understanding and an attempt to clarify. Stories, analogies and metaphors are interwoven into the very fabric of our lives from childhood onwards. Here the author explains how figurative language, and the telling of meaningful stories, can be used in the therapeutic environment to enable clients to understand and, hopefully, alter their perspective; thus allowing them to change unhelpful beliefs about themselves, the way that they behave and think. Blenkiron explains the therapeutic use of stories in the CBT setting; the need for them to be understood by both parties; the fact that some of the stories/analogies may arise from the client themselves and the way that a good CBT therapist can use these. He explores the risks, and benefits, of using figurative language and the need for a therapist to be flexible in their approach and be "in tune" with their client. As he explains, "CBT is about focussing on what matters to the clients as much as what is the matter with them." Ideally, a good therapeutic story should be one which aims to improve the quality of a person's life. He argues that stories/analogies cannot be applied "like a prescription" - there is no one size fits all. Just as some antibiotics may suit a patient, others may find the same medication unhelpful or even harmful. The CBT therapist must remain mindful of this when using stories and analogies.
A plethora of useful stories and analogies are included. All of them clearly linked with the types of mental distress for which they will be appropriate. Blenkiron gives a compelling argument for the use of stories/analogies in a wide range of mental, and physical, problems including: depression, anxiety, post traumatic stress disorder, personality disorders, psychosis, anorexia and cancer. He is realistic in his acknowledgment about the complementary use of medication and diagnostic labels within the CBT pool. This is not a book which dismisses the use of medication, but instead embraces it as a means of stabilising a person so that they are able to engage with CBT.
The book is extremely well researched. This is evidenced by the quantity, and quality, of Blenkiron's range of stories, analogies, metaphors and similes. In addition, he employs a lavish sprinkling of quotations and proverbs from sources as diverse as Roman philosophers, political figures, writers and even Groucho Marx! They are a helpful, enlightening and often humorous condiment to his text.
It's an excellently structured piece of work. Each chapter gives a brief overview of the topic to be discussed which is then elaborated in more detail. The text is interspersed with tables, pictures, diagrams, graphs, quotations and case histories. While he debunks myths about what CBT isn't, he explains what it is and how it can be effectively used in a therapeutic relationship. He gives clear guidance on the "dos" and "don'ts" of using CBT including the possible pitfalls for therapists. This includes boxes of "How not to do CBT" which should enable the therapist to identify problem zones. He also gives advice for trainees and supervisors. Useful stories are offered for each "diagnosis" in addition to case histories and practical help for the client. Each chapter concludes with a summary and a table of key points. In his appendix, Blenkiron lists the stories/analogies which appear for each chapter/condition enabling the reader to access them quickly. Even within every chapter, Blenkiron refers the reader to where a story has been used before or may be useful. This quick reference guide dispenses with the need to flick forwards and backwards among pages in the attempt to locate a specific, helpful therapeutic story.
I was surprised to see a chapter on physical health as I had not realised that CBT could be beneficial outside the realms of mental ill-health. Although it is a welcome addition, I would question Blenkiron's inclusion of eating disorders within this section. While undoubtedly anorexia and bulimia lead to physical health problems their roots, I would argue, lie in mental distress. This chapter raises other issues for me. While the debate around how to address people with mental health issues (service user, patient, client or even customer) continues, Blenkiron doesn't tackle it, but instead adds another controversial dimension. Throughout the book, the author has emphatically used the term client as "one who uses the services of another" in preference to patient which he explains as meaning "one who receives treatment". However, when discussing physical health, Blenkiron adopts the term patient instead. He explains this shift because the word patient derives from the Latin patiens meaning "to endure or suffer". This would seem to infer that those who have psychological problems do not endure and suffer in the same way as people with physical ill- health. Similarly, Blenkiron notes that a common theme with depression is self-pity ("poor me"). While I acknowledge Blenkiron's professional experience in this area, I have yet to meet anyone with clinical depression who exhibits this alleged trait. Moreover, is Blenkiron suggesting that this attribute doesn't arise in people with other mental health diagnoses or cancer etc?
In addition, there seems to be another anomaly in Blenkiron's use of "inspirational stories". He argues these can be used to enable a client/patient to deal with their condition. However, this would appear at times to be na¿ve and ill-founded. While he acknowledges that "inspirational stories" could be problematical for someone with a physical, or terminal, illness as it may make them feel "only more pressure to cope", he fails to make the same concessions for people with mental health problems. In particular, I would question their helpfulness in terms of childhood trauma. Blenkiron's "Overcoming Adversity: true stories" focus mainly on physical disability and poverty. They do not address the variety of extenuating circumstances which may leave a person from an abusive background "frozen in time". Being told about people who have been able to succeed in spite of adversity could only exacerbate the sense of shame, guilt and failure which they already experience. Finally, I feel that including Charlie Chaplin, with his predilection for young girls, on the same page as childhood sexual abuse to be an unfortunate example.
Notwithstanding the above comments, this is a clear and comprehensive study. The author's competence and expertise is demonstrated throughout the book. Paul Blenkiron suggests that the reader may wish to view it "like a box of chocolates" from which they may want to only select their favourites. However, I would recommend reading it, as I did, from cover to cover savouring every word. Only then can you decide which parts of the text are likely to be helpful in therapeutic practice. I believe that this book offers all therapists an invaluable toolkit, and adjunct, for their profession and one which I feel will prove useful for many years to come.