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CBT? EFT? EMDR? Hypnotherapy? XYZ? ...

I was recently asked by someone if I do "exposure response prevention" (ERP) with clients with obsessive compulsive disorder (OCD). I said I do, and she said that she didn't realize that I do. I replied that I do cognitive-behavioural therapy (CBT) and ERP is one of the techniques that works for OCD. She continued to ask me if I do ERP as well, or only CBT with OCD. I was literally speechless for a few minutes. Perhaps I should have said that ERP is one of the CBT techniques that works for OCD.

I am always fed up by the question "what psychotherapeutic approach do you use?". And I am asked if I do CBT, EFT, EMDR, hypnotherapy, ERP, etc. I learnt all of the above, but answering questions like these is like a cook answering the questions if he/she knows how to do beef, if he/she does beef only or if he/she does grills.

Clinical Psychologists are trained as scientist-practitioners, who deliver treatments and use specific techniques that are proven to be effective to deal with particular psychological and mental conditions. The selection of approaches and techniques is based on the scientific understanding of cognitive (C), behavioural (B) and emotional (E) processes, and how and why certain techniques and approaches work for what specific conditions. For simplicity and because a big proportion of the empirical studies look into these processes, it is easier to say I do CBT than saying that I am using a science-based approach, but I am always reluctant to say the former. Some people may hear or even learn basic CBT, and may think that CBT is all about the notion that what we think affects how we feel, and it involves teaching one how to think in order to affect one's mood. However, we know from neuroscience studies that information reaches the amygdala before reaching the frontal lobe, so that emotional responses have been generated before we start to appraise what the feeling is about and how we think about the situation, and at least this is what happens for fear and anxiety. We now know that changing how we think does not necessarily change how we feel, particularly on the spot when we are intensely emotionally aroused. There is a brief refractory period that follows an emotional arousal where one cannot encode information that is contradictory to the current emotional state. That explains why one is not always successful in applying cognitive restructuring strategy on the spot when one is in a severe depressive state, for instance.

CBT is an umbrella term to describe an approach that places the emphasis on how one's cognitive, behavioural and emotional processes interact with each other to bring about and perpetuate one's mental problem. By "cognitive", it does not only mean what we think, but also how we think, how we attend selectively to information, how we respond internally to emotion, etc. That's why, for instance, some mindfulness techniques may be more helpful than cognitive restructuring to help someone to be aware of the automatic cognitive processes underlying an emotion. By "behavioural", it involves not only the so-called behavioural experiments, but more importantly, how behavioural conditioning affects our emotional and physiological responses. For example, operant conditioning may be the most widely understood phenomenon, where one's attempt to leave a crowded and noisy shopping mall in order to relieve one from anxiety will in turn strengthen the link between the crowded mall and the physiological components of anxiety. By "emotional", our feelings are not only a doorway to access how we perceive and appraise the situations, but also serve as a bridge to longer-term experiences that shape our belief system. That's why some emotion-focused therapy techniques are useful in helping someone to explore and understand their feelings and access the meaning and source of origin . Moreover, CBT is an umbrella term, which means that there are variations in CBT, and different techniques are used for different conditions. There are different CBTs for different types of anxiety disorders. CBT for eating disorders is different from CBTs for different types of depressive disorders, for instance.

I employ an approach that look into the C, B and E factors that bring about, sustain and perpetuate the problem(s) at the present. It is in contrast to other paradigms, such as neo-Freudian, which believes that the core of the problems rests on the unconscious psychic that was formed during childhood. They tend to think that only "resolving" what happened in the past, which may be hidden beyond our consciousness, can solve the problems at the present. I think the term "resolving" is loosely defined, and I do not know how to change the past. However, we can change how we now perceive and interpret, and how we feel about the past. In fact, we now know that how and what we think and feel, be it at present or previously, are interconnected and stored in our brain in a web-like manner, so that concepts, feelings, ideas, physiological states, etc. are linked together according to their occurrence, proximity, salience along with our idiosyncratic daily experiences and upbringing. Some of these are not conscious in everyday life but are activated by stimuli or information that look, sound or feel similar to them. For example, a perfectionist may sense a rejection when tiny flaws emerge in his work or relationship, because a sign of flaw associated the sense of humiliation he experienced in his childhood when he was bullied due to his sexuality and he was told that he was a flawed man. In this case, he makes sense of why he is too fixated on being flawless in his work all along his life, and he now can choose to learn ways to change it.

When I learnt Solution-Focused Therapy many (many) years ago as a counsellor or psychotherapist, I was told that I did not have to know the mechanics of a lock but I only needed the right key to solve the puzzle. This is probably why many people learn different therapy approaches, e.g., CBT, EFT, EMDR, hypnotherapy, etc., like a recipe and follow the manuals without actually knowing why. However, this is no excuse to a Clinical Psychologist. A Clinical Psychologist is the locksmith who knows how different locks are made and work, and choose the right keys for different types of locks.

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