Fifty Shades of Brown Sauce

It was only a matter of time before I crumbled and jumped onto the current fad for subjugation – which is my understanding of the literary phenomenon that has spawned, in a manner of speaking, a whole industry. However, I am not sure how one can crumble and jump at the same time.

Subjugation is a recurrent theme in my work with clients as they struggle with issues around self-esteem and assertiveness. Many people learn from a young age that they can gain acceptance by others only by subjugating their own physical and emotional needs. It is not just a question of self-denial, it is a matter of denial of the self. Subjugation is a form of maladaptive schema in terms of cognitive behaviour therapy formulation.

I remember one client describing how she would not put brown sauce on her cooked breakfast because the smell of it disturbed her husband. Years of bacon and eggs without brown sauce. It seems like such a small thing, but we recognised it as a potent emblem of how in this and in many other ways she subjugated her needs within the marital relationship. It became a short-hand way to flag similar patterns of behaviour in the relationship.

My client was like a rose kept in a darkened room, unable to flourish because of both the constraints placed upon her and her acceptance of those constraints.


Therapist as Programmer

We have recently witnessed a large increase in the number of people trained in cognitive behaviour therapy (CBT). This is a welcome development as it allows more people to benefit from this very effective form of psychotherapy.

However, there is a danger that consumers and commissioners of mental heatlh services lack the discriminant ability to recognise that there are differing levels of skills and training in CBT. Differences can be attributed both to variations in the quality and style of teaching, and to the knowledge and competencies of the individual CBT therapists. These distinctions are well-understood by people closely involved in training and service-delivery, but they may not be shared by the population as a whole. There are, for example, differences in training for the low-intensity and high-intensity CBT therapists currently working in primary care – mostly in “IAPT” (Improving Access to Psychological Therapies) services.

A further important consideration is the quality of clinical supervision that the practitioners receive on a regular basis. This helps to ensure that therapists recognise and work within their range of competence – many people with complex psychological problems will need input from a therapist with more training and experience, typically (but not exclusively) from a clinical or counselling psychologist.

To illustrate, I think we can find an analagous distinction between the many people who can use computer software packages and the few who actually understand the underlying programme languages. It is not necessary to know how the code is constructed in order to use the software, but it becomes important when the programme is not working as it should. In therapy terms, many CBT practitioners can apply the basic principles of treatment but encounter difficulties when confronted by  the idiosyncracies of people with enduring and complex psychological problems. This is where the therapist with a deeper understanding of the psychological substrates – e.g., motivational processes, emotional regulation, information processing, learning and developmental aspects – is able to step outside the limitations of manualised approaches.