Introduction
Cognitive behavioural psychotherapy (CBT) research is primarily positivist and empirical. However, its practice may be interpretable as both objectivist and subjectivist (Richardson and Bowden, Reference Richardson and Bowden1983). For example, a therapist and patient may hold subjectively true but differing beliefs (i.e. pluralist/subjectivist). The objective truth may differ from both their positions. The task of therapy then becomes the confirmation of the degree of inaccuracy. Both therapists’ and patients’ beliefs may be a function of their developmental experiences (e.g. Beck, Reference Beck1976; Young et al., Reference Young, Klosko and Weishaar2003). As such, each CBT therapist’s developmentally acquired schemata may influence his/her understanding and application of theory. This pluralist perspective raises the possibility of multiple versions and interpretations of CBT theory, each slightly differently coloured by the therapist’s schemas. CBT’s reliance on positivist research risks marginalizing the influence of this subjectivist, pluralist perspective.
Positivist research has been central to the development of CBT and its empiricism. Notwithstanding the significant influence of positivist research, I propose that there is a need for a pluralist research approach in CBT. By marrying a self-experiential, therapist self-development approach [self-practice/self-reflection (SP/SR); Bennett-Levy, Reference Bennett-Levy2006] and an adapted qualitative research and writing methodology (autoethnography; Anderson, Reference Anderson2006; Ellis and Bochner, Reference Ellis, Bochner, Denzin and Lincoln2000), it is possible to develop a credible, subjectivist personal case study-based methodology for SP/SR in CBT. I will offer this proposal in six sections: (1) a brief outline of theory (autoethnography and CBT and the worry model), (2) a description of the methods of self-reflection I used, (3) an outline of my socio-cultural background, (4) an example of my worry experience and self-practice of CBT for worry (5) an example of the influence of my self-practice on my clinical practice, and (6) a synthesizing discussion.
Theory
Autoethnography
Autoethnography is an approach to qualitative research and writing, whose objective is the description and systematic analysis of personal (auto) experience, in order to understand cultural (ethno) context (Deenshire, Reference Deenshire2013; Ellis et al., Reference Ellis, Adams and Bochner2011). It can be either evocative (Ellis and Bochner, Reference Ellis, Bochner, Denzin and Lincoln2000) or analytical (Anderson, Reference Anderson2006). In evocative autoethnography, the writer/researcher selectively and retrospectively focuses on his/her own experiences, analysing epiphanies (Ellis et al., Reference Ellis, Adams and Bochner2011). The focus is primarily on emotion evocation, so that issues which may be affected by social and cultural structures (e.g. identity, emotionality, the relational nature of experience, and institutional stories) can be examined (Haynes, Reference Haynes, Hoque, Parker, Covaleski and Haynes2017). It is unashamedly subjective, rejecting generalization of experience and the representation of the other (e.g. Anderson, Reference Anderson2006).
Analytic autoethnography also focuses on personal experience and its cultural contexts, but places greater value on a sense of objectivity, not simply emotion evocation (Haynes, Reference Haynes, Hoque, Parker, Covaleski and Haynes2017). It generalizes to broader ‘social phenomena’, emphasizing theoretical analysis of specific personal experiences. Anderson (Reference Anderson2006) defines its distinguishing features as: (1) complete member researcher (CMR) status, (2) analytic reflexivity, (3) narrative visibility of the researcher’s self, (4) dialogue with informants beyond the self, and (5) commitment to theoretical analysis.
Exo-autoethnography, a recent addition to the autoethnographic stable, emphasizes transgenerational trauma transmission (Denejkina, Reference Denejkina2017). It analyses the proxy experience of trauma through its impact on the ‘other’ (e.g. a child’s proxy experience of a parent’s trauma). It builds on evocative and analytic autoethnography, adding the understanding of ‘(1) a history that impacted the researcher by proxy; and (2) personal and community experience (ethno) as related to that history’ (Denejkina, Reference Denejkina2017; p. 2).
The autoethnographic researcher/writer uses tenets of autobiography and ethnography, and ‘retrospectively and selectively write[s] about epiphanies that stem from, or are made possible by, being part of a culture and/or by possessing a particular cultural identity’ (Ellis et al., Reference Ellis, Adams and Bochner2011; p. 8). Adams and Manning (Reference Adams and Manning2015) stress the importance of the use of memories, personal experience and storytelling as defining features of autoethnography. Except for a few examples (e.g. Putri et al., Reference Putri, Poerwandari and Rusli2018; Short et al., 2013), there is a dearth of CBT autoethnographies.
I propose that a pluralist perspective has been an essential omission in the development of CBT-therapists and their theories. This may be especially pertinent when considering the assertions that culture flows through self and vice versa (Bochner and Ellis, Reference Bochner, Ellis, Ellis and Bochner1996) and all truth is contingent on human representational activity (Rorty, Reference Rorty1979). CBT theory and practice may be representational, flowing through the therapist’s self, while the self of the therapist flows though his/her understanding and application of theory. Such an interpretivist perspective may be a perfect fit for SP/SR (Bennett-Levy, Reference Bennett-Levy2006), a self-focused practice modality that allows CBT therapists to self-apply and reflect upon the techniques they use with patients (see, for example, Bennett-Levy, Reference Bennett-Levy2006). SP/SR leads to a deeper sense of knowing (e.g. Bennett-Levy et al., Reference Bennett-Levy, Turner, Beaty, Smith, Paterson and Farmer2001) and a personal understanding of the theory (Chigwedere et al., Reference Chigwedere, Thwaites, Fitzmaurice and Donohoe2018). It may meet the goals of therapists’ personal training therapy (Chigwedere et al., Reference Chigwedere, Thwaites, Fitzmaurice and Donohoe2018), but it is difficult to locate peer-reviewed journal publications of the first-hand SP/SR experiences of CBT therapists. This autoethnography-informed personal case study describes a marrying of SP/SR and autoethnography, in an attempt to bridge this gap.
Why this autoethnographic personal case study in this way?
CBT, SP/SR and this autoethnography
Historically CBT attributed therapeutic change to the faithful application of empirically supported techniques, not the relationship or the self of the therapist (Laireiter and Willutzki, Reference Laireiter and Willutzki2003). Consequently, although acknowledged, CBT therapist self-exploration was not widely practised. SP/SR is one of the new approaches leading a change in CBT culture. Although SP/SR encourages therapists’ subjective experience of theory, its research literature has been overwhelmingly objective and positivist. Together, SP/SR and autoethnography potentially achieve more than the sum of their parts, turning therapist self-experience into rich, first-hand research material. This paper describes my borrowing from the principles of autoethnography to analyse and write-up my SP/SR. My objective was to (1) autobiographically reflect on worry in my life and its possible social context, (2) view that experience through the lens of the CBT theory, (3) reflect on that theory through my personal experience of it, and (4) examine the impact of my new learning upon my clinical practice.
I explicitly borrowed from principles of autoethnography, in particular features of analytic autoethnography (Anderson, Reference Anderson2006) in order to develop an SP/SR relevant, subjectivist research approach. As such, in this personal case study, I am a complete member researcher, reflexive, narratively visible, dialogue with informants beyond myself and engage in theoretical analysis. I have replaced culture with theoretical perspectives by borrowing Bochner and Ellis’s (Reference Bochner, Ellis, Ellis and Bochner1996) synergy of self and culture. I suggest a synergy of the therapist’s ‘self’ and CBT culture and theory, thus replacing socio-cultural with ‘socio-theoretical’. My objective is to better understand and highlight the haptic nature of the ‘theory-researcher/therapist-patient’ interface.
Haptic, defined as ‘relating to the sense of touch, in particular, relating the perception and manipulation of objects using the senses of touch and proprioception’ (https://en.oxforddictionaries.com/definition/haptic), is an apt descriptor for the functions of SP/SR and therapy. The theory affects me, so I can affect the patient, which in turn changes my understanding of that theory. Unfortunately, positivist research takes the ‘me’ out of this process. In standard autoethnography, experiences are reconstructed using hindsight (Bruner, Reference Bruner and Folkenflik1993; Denzin, Reference Denzin1989; Ellis et al., Reference Ellis, Adams and Bochner2011; Freeman, Reference Freeman, Daiute and Lightfoot2004), but in this personal case study I mirrored the deliberate, prospective, change-focused nature of SP/SR and psychotherapy, thereby making the theory as important as my personal experience. For this reason, it was necessary to have an identified theory/model within which my experience was analysed. I therefore use a reductionist model (CBT model of worry), which is not typical of standard autoethnography.
CBT models of worry
CBT-based generalized anxiety disorder (GAD) models of worry include avoidance of worry (Borkovec and Inz, Reference Borkovec and Inz1990), intolerance of uncertainty (IoU; Dugas et al., Reference Dugas, Gagnon, Ladouceur and Freeston1998), meta-cognitions (Wells, Reference Wells1995), and emotional dysregulation (Mennin et al., Reference Mennin, Turk, Heimberg, Carmin, Reinecke and Clark2004). In brief, the main feature of GAD is ‘excessive and uncontrollable worry and anxiety about a number of situations’ (Dugas and Robichaud, Reference Dugas and Robichaud2007; p. 7). Worry in GAD is diffuse and about almost everything, so that it can spiral from one topic to another, although the worry topics are no different from those of non-worriers (Dugas and Robichaud, Reference Dugas and Robichaud2007). It centres on remote future events and negatively affects quality of life. CBT worry research has largely been patient-, not therapist-focused. It is unlikely that CBT therapists do not worry sufficiently to warrant researching. Consider the following personal experience:
I am at a conference and due to travel early in the morning. My colleague (A) will drive. I wake at 8 a.m. and message her. No response. She is an early riser and would usually have knocked on my door by now. I head for breakfast. She is not there. I telephone her. No response again. I have an image of her dead in bed. I recall a recent story of an apparently healthy colleague who died suddenly from a heart attack. She just dropped dead after returning from lunch with her friends. What if the same has happened to my friend? What if I have to identify her body? Who will I call? How will I react? I run into another colleague, B.
‘Where is A? I thought you guys had gone already’, she says.
‘No, I am waiting for her. We’ll have breakfast and then set off’, I reply.
‘I knocked on her door and she didn’t respond. That’s not like her. I wonder if everything is ok’, she says, voicing my own fears.
‘I don’t know. Let me try to call her again’, I say, trying to sound calm. I dial her number. ‘Morning’, A says, chirpy as ever. She explains that she had taken a shower, then took a long telephone call. She does not want breakfast. I tell B.
‘I was really worried there for a second’, says B. ‘I was having all sorts of catastrophic thoughts’.
‘Me too’, I say. ‘I think this is what our patients go through when they worry’.
‘What a thought’, she says. ‘Being a cognitive behavioural psychotherapist does not render us immune to worry, does it?’. We laugh.
The IoU model (Dugas et al., Reference Dugas, Gagnon, Ladouceur and Freeston1998; Dugas and Robichaud, Reference Dugas and Robichaud2007) hypothesizes four contributory factors to the development and maintenance of worry: (1) IoU (2) positive beliefs about worry (3) negative problem orientation, and (4) cognitive avoidance (Dugas et al., Reference Dugas, Gagnon, Ladouceur and Freeston1998). IoU is ‘a dispositional characteristic that results from a set of negative beliefs about uncertainty and its implications’ (Dugas and Robichaud, Reference Dugas and Robichaud2007; p. 24). Such a characteristic has been associated with beliefs that uncertainty is ‘stressful and upsetting, that being uncertain about the future is unfair, that unexpected events are negative and should be avoided, and that uncertainty interferes with one’s ability to function’ (Dugas and Robichaud, Reference Dugas and Robichaud2007; p. 24). In my own worry experience, I do not quite recognize this global characteristic as described by Dugas and colleagues.
Problematic worrying is hypothesized to be associated with high levels of anxiety, due to a tendency to make threatening interpretations of ambiguous information and to search for unattainable absolute certainty. I am certainly not aware of seeking absolute certainty, but my worries involve catastrophic thinking. Compared with non-worriers, worriers are hypothesized to need more information in moderately ambiguous situations, which results in reduced confidence in their decisions. Worrying has been associated with negative problem orientation (i.e. viewing problems as threatening, doubting own problem-solving skills, and being pessimistic about outcomes). Although I recognize a tendency to need more information when worrying, I do not recognize the negative problem orientation as described.
The model also incorporates the metacognitive model (Wells, Reference Wells1995), which proposes that worrying is associated with positive (e.g. ‘worrying is helpful’) and negative beliefs (e.g. ‘worrying will make me ill’). Finally, worrying involves cognitive avoidance (the use of overt and covert strategies to avoid threatening cognitions), is generally verbal linguistic (e.g. hypothetical ‘what if…’ scenarios), and is free from imagery (Borkovec and Inz, Reference Borkovec and Inz1990). Such avoidance is hypothesized to reduce unpleasant autonomic arousal, which negatively reinforces its use and maintains beliefs about worry. Although I work with worriers, recognize all these concepts and have faith in the model, I have never truly explored them in my own worry. Dugas and Robichaud (Reference Dugas and Robichaud2007) outline a six-module treatment approach:
(1) Psychoeducation to increase understanding and awareness of uncertainty;
(2) Uncertainty recognition and behavioural exposure to real life situations (i.e. in vivo exposure to events occurring now);
(3) Re-evaluation of the usefulness of worry;
(4) Problem-solving training;
(5) Imaginal exposure to hypothetical situations that have not yet occurred;
(6) Relapse prevention.
My methods
My self-application approach
I took a prospective approach, rather than a strictly retrospective one recommended in standard autoethnography. However, I first reflected on the developmental and social context of my worry. I then defined my worry as ‘moments when I felt noticeable levels of anxiety associated with cyclical thoughts that felt uncontrollable and troublesome’. I then saved the worry formulation diagram from Dugas and Robichaud (Reference Dugas and Robichaud2007) onto my computer, so that I could use it to monitor and analyse my worry experiences. Initially, I attempted to deliberately activate my own worries. This felt rather contrived and unsatisfactory and my anxiety was very low. Therefore, I monitored my worry events over a period of 6 months, applying CBT interventions, as would be the case with worry/GAD patients in Module 5 of Dugas and Robichaud’s (Reference Dugas and Robichaud2007) protocol.
To avoid interrupting the experience too much, I did not make reflective notes until after each worry self-practice event. When reflecting, I completed the Dugas and Robichaud formulation diagram, then wrote a separate reflective summary of each worry event, noting when I was worrying, the triggers of the worry, the types of thoughts I was having, my affective responses and what happened when I self-applied the CBT interventions. I also noted anything else that caught my attention, either due to its confirmation of the model or otherwise. I repeated this with each new worry event (n = 8), reviewing the formulation and noting any subjective experiences. Except for one event (relating to hearing that my four-year-old son – who was abroad with his mother – was playing in a place where I know someone had been bitten by a snake), all the worry events occurred at night. My method of analysis was loosely informed by deductive thematic analysis (Braun and Clarke, Reference Braun and Clarke2006) and philosophically, an epistemological consideration of the phenomenon of worry. As I do not have a diagnosis of worry or GAD, I needed to confirm that my worry experience had some similarity to clinically diagnosed worry. I therefore confirmed my findings with patients (n = 6) and fellow CBT therapists (n = 8). Rather than reporting themes from my experiences, I will use illustrative composite examples to tell the ‘story’ of my SP/SR practice.
Results
Me, SP/SR and autothenography
I was born in Zimbabwe, then called Rhodesia. I struggle to find a satisfactory answer to the question, ‘Where are you from?’ Firstly, my birth country changed names after my birth. Secondly, I have lived abroad in multiple countries for the greater proportion of my life. My cocktail of experiences means that I have multiple cultural influences. I am often amazed by the resilience of my early familial and cultural messages. At the risk of offensive over-generalization, I experienced traditional Zimbabwean culture as collectivist, discouraging individuality. One’s good or bad deeds were a reflection on the family, which lead to an ever-present shadow of guilt and shame.
Professionally, I am a CBT therapist, faithfully practising the modality but influenced by a range of theoretical perspectives. I am wedded to CBT’s rational empiricism, but when first introduced to SP/SR, I felt, rather than rationally identified, its importance. Having thrown myself headfirst into it to PhD level, I was frustrated by the lack of ‘me’ in my SP/SR writing. Through SP/SR, I was developing personal and theory-focused hypotheses. I self-practised a range of CBT interventions and more recently, I have focused my SP/SR attentions on CBT theories and models, not just interventions. I have focused on CBT models of worry but until I discovered autoethnography, I had no way of expressing them. However, autoethnography seemed too focused on emotion evocation. I do not merely want to evoke emotion in my reader but rather, to analyse personal experiences using theory in order to better understand that theory. That is the point of SP/SR for me, not simply to understand myself but theory and its application. I needed to adapt existing approaches to autoethnography or at least borrow from them.
Worry and me
My tendency to worry has been with me for as long as I can remember. As a child, I worried about growing up to be a ‘proper man’. Why? There were comparisons; comparisons between individuals, between families. I heard about the acceptability or otherwise of people based on family of origin. It was important to be acceptable and one’s family of origin impacted on how one was perceived. So, when I started school, I worried about fitting in. I sensed that I was materially better-off than my peers. I was 5 or 6 years old. Fearing being perceived as different, I would remove my warm coat or jumper and leave it hanging on the garden fence and shiver to school. I didn’t want my good clothing to give me away.
In my teenage years, my best friend had a motorbike and I had a bicycle. One day, fearless and reckless as young boys can be, I held onto his shoulder while he opened the throttle. We wanted to go faster and zoomed along dangerously. We were stopped by the police, who loaded us and our vehicles into the back of a truck. They threatened to lock us in police cells and to throw away the keys. They certainty succeeded in scaring us but when they spoke of calling our parents, that did it. My friend, who was of white European decent, seemed unperturbed. I shook, virtually in tears. The thought of the disappointed look on my mother’s face was too much to bear. She would be disgraced, and I would be the cause. Perceptions were everything. This was spelt out for me some years later when I met a girl from Zimbabwe and she introduced me to her family. Later she told me that her aunt had become quite excited when she discovered my surname. ‘The Chigwederes are a very good family’, she had apparently said.
I rarely consciously worry in the day. I often studied before dawn as a student, having woken up early, worrying about failure. However, the tentacles of worry silently stretch into my daytime activities and decisions. Activities such as doing things for myself, overt expressions of pleasure in my own achievements or buying expensive personal goods can activate shame. Only recently, one of my supervisees asked me why the name on my office door does not say ‘Dr’. Why indeed? It appears that my worry in the day involves subtle avoidance behaviours but at night it is bold, sweaty, tense and uncomfortable. It imitates the worry that my patients describe. For this reason, I decided to focus on the worry as part of my SP/SR work.
Example of my worry-focused SP/SR practice
I am briefly up in the middle of the night. When I return to bed, I cannot sleep. I am in a nightmarish whirlwind of thoughts, in which my recently purchased house is worth far less than I paid for it. ‘What if the estate agent duped me? What if I am stuck in a worthless pile of bricks for the rest of my life?’ This is worry. In keeping with Dugas and Robichaud (Reference Dugas and Robichaud2007), these are my ‘What if…’ scenarios, my hypothetical worrying. As described in the model offered by Dugas and Robichaud, my heart beats a frenetic rhythm. I am tense and anxious. Rivers of sweat drench my pillow. As an experienced CBT therapist, I know not to problem-solve hypothetical worries. I start SP/SR, imaginal exposure to an apocalyptic hypothetical homeless future. It is difficult to sufficiently disengage from the worry to do the exposure. I am surprised at how difficult it is to vividly picture the scene. There are too many possible worst-case scenarios. I am reminded of a former patient who described this approach to imaginal exposure as being like trying to corral a fleeing herd of horses. Finally, I create a composite worst-case scenario. I paint a picture of it in my mind’s eye, as detailed as I can. Despite knowing what to expect, the intensity of my anxiety surprises me.
I feel as though I am usefully searching for solutions. In keeping with the metacognitive model described by Wells (Reference Wells1995), I have a sense of doing something positive when worrying. What surprises me, and is not clearly stated in the theories, is the sense of reality associated with my ‘verbal-linguistic worries’ as described by Borkovec and Inz (Reference Borkovec and Inz1990). Also, although verbal, my worries are accompanied by vague imagery, like grainy premonitions of what will eventually come to pass unless I find solutions.
It is difficult to reflect without affecting my experience. Besides the hypothetical ‘What ifs…’ popping like corn in my head, I must monitor my thoughts, rate my anxiety and think of the theory. This is what I make my patients do. Although I do not time myself, habituation seems to come quickly. However, while reflecting on the experience, new ‘What ifs…’ are rising like phoenixes in the corners of my awareness. On a whim, I do something different. Earlier in the day, I heard a news reports of a slowdown in house prices. This is in keeping with the findings that worry is associated with a tendency to make threatening interpretations of ambiguous information (Dugas and Robichaud, Reference Dugas and Robichaud2007). I know this to be the trigger for my worry, but it has been the focus of neither my conscious worry, nor my exposure efforts.
I return my mind to the news report that ‘House price rises are showing signs of slowing down’ and the associated sense of ‘not knowing’. I resist my mind’s efforts to move towards ‘What ifs…?’ It tugs like a spooked horse on a leash. I pull it back, and back again. What I feel is not quite anxiety, but a discomfort, an uncertainty. I ‘sit’ with it, and an accompanying sense of shame, as though possible homelessness equates to letting people down. I know where this comes from – my childhood. The implied messages of failure. The lessons of self-sacrifice and subjugation. I am reminded of this by the current slow-down in the housing market. I hold the thought, resisting my mind’s desire to curl away from it and its discomfort like a plastic bag near a fire. Soon, I catch my mind wandering off, relaxed, as though taking a gentle summer stroll. I sleep. In the following weeks, I return to this exercise with different worries. I attempt the exercise with and without accompanying images. Even though sometimes the worry returns, the result is generally the same.
Me, the model and the patient
Unsure if my experience had any validity outside of my own worry, I have done two things: (1) I have discussed my own hypotheses with eight professionals (e.g. my colleague A, above), and (2) as I am not clinically diagnosed with worry/GAD, I spoke with six clinically diagnosed worriers to confirm the similarity between my experience and theirs. I have since tentatively adapted my clinical questioning to ask about what I have termed ‘current uncertainty’ and the sense of premonition. All the patients endorsed the sense of a current uncertainty before hypothetical worries, which have the feel of eventualities (what I have called a ‘premonition bias’). For example, one patient said, ‘When I am worrying, the possibilities become eventualities’. This is very similar to the experience I described above, and I have tentatively applied the same approach to patients who were struggling with the normative imaginal exposure approach. The following composite vignette, based on a number of patient interactions, is illustrative.
Patient: I woke up at 3 a.m., all hot and bothered, my mind racing. I was thinking things like, ‘I have a meeting tomorrow, what if I am not sharp enough? What if I am asked a question and I can’t answer? What if I am not quick enough? What if I don’t get back to sleep and I am even more tired? What if I am not good company and am cranky with my family?’ (hypothetical worry)
Therapist: What does it feel like you’re doing, when you’re worrying? Is there an objective?
Patient: Like I am trying to find an answer (worry objective)
Therapist: So, when you think that you won’t be able to answer questions or something like that, how does it feel? For example, like your own thought that’s just a possibility or does it have a sense of reality, like it could or will eventually happen?
Patient: Oh, like it’s real. Definitely, like it will happen (sense of premonition/eventuality)
Therapist: So it makes sense that you were trying to problem-solve it then. Did you find an answer that worked?
Patient: I did, several answers, but then I worried again (negative reinforcement)
Therapist: Sounds like it doesn’t really work in the long run. What was the trigger of this worry?
Patient: I had this meeting in the morning and I couldn’t sleep (trigger)
Therapist: I see. Tell me, how would you complete this statement, ‘I have a meeting and I can’t sleep. I don’t know…?’
Patient: … I don’t know how I am going to function? (current uncertainty)
Therapist: Can you just hold on to that thought, just focus on it? Take yourself back to that bed. Hear that thought ‘I don’t know how I will function!’ What’s that like? (exposure to current uncertainty)
Patient: How will I cope? These guys are intelligent and what if they’re asking intelligent questions? (future focused hypothetical worry)
Therapist: So, your mind wants to go to that future possibility. Is that what was happening at 3 a.m.?
Patient: Yes
Therapist: Can you resist doing that right now? Just stay in that bed with that sense of not knowing? Use that as your anchor when your mind wants to go to those ‘what ifs …’. What happens?
Patient: It’s uncomfortable. My heart jumps a bit, some tension in my chest and stomach. (affective response). It’s hard not to try to do something about it (urge to cognitively avoid current uncertainty). At night I would think something nice (covert avoidance) or get up and go downstairs to distract myself (overt avoidance)
As with my own experience, targeting the current uncertainty was often described positively; for example: ‘This is better. You’re catching the problem at its onset. The other way (i.e. targeting the hypothetical worry), it’s like trying to close the stable door after the horse has bolted’.
Discussion
I borrowed from autoethnography to add to my SP/SR. I self-practised CBT for worry, reflecting on my personal experience, thereby deepening my knowledge of the model. Compared with standard autoethnography my approach was pseudo-experimental and prospective, not retrospective. This approach enhanced my reflection on my worry experience and the worry theory. As proposed by Bennett-Levy and colleagues, SP/SR practice deepened my sense of knowing. Besides awareness of how difficult it is to hold the imagined feared scenario, which I regularly ask patients to do, I became aware that the majority of my worries were informed by messages derived from my familial and cultural developmental experiences. To my knowledge, this is the first autoethnography informed personal case study of SP/SR in CBT.
The IoU model of worry as described by Dugas and Robichaud (Reference Dugas and Robichaud2007) held personal credibility for me. I was able to identify the different components of the model in my worry experience but there were small but significant areas of divergence. For example, the theory proposes that worry is diffuse and jumps from one topic to another (Dugas and Robichaud, Reference Dugas and Robichaud2007). Although this appeared to be the case, once I changed my imaginal exposure focus, I experienced a sense of ‘current uncertainty’, an involuntary core belief-informed response to specific triggers. My apparently diffuse worries seemed to be associated with a small range of core belief domains (Beck, Reference Beck1976). This may be worth considering in future IoU and worry research, especially as a small number of patients confirmed similar experiences. Such core beliefs may represent developmentally salient implicit learning and unwanted outcomes (e.g. familial shame and disgrace, in my case) activated by ambiguous explicit current events (e.g. the news report).
My worry seemed to function as a means of cognitively avoiding and escaping from the discomfort associated with the current uncertainty. I seemed to seek certainty and solutions by escaping into hypothetical worry. As such, my worry experience supports the theory (e.g. Borkovec and Inz, Reference Borkovec and Inz1990; Dugas and Robichaud, Reference Dugas and Robichaud2007). However, my experience was that the hypothetical scenarios had a ‘premonition’-like quality, as though representing realities that would eventually come true. As such, my cognitive and behavioural efforts seemed productive and positive. Feedback from the experiences of a handful of patients seemed to support this hypothesis. This may be a worthy area of focus for research, which may provide a hitherto unclear rationale for the notion of positive meta-worry (Wells, Reference Wells1995).
Strengths and limitations
This is a combination of elements of case study and autoethnography, which is unashamedly my subjective experience and should be interpreted as such. Efforts to use personal experience to inform wider theory may be going too far beyond the ‘data’. It is difficult to generalize from an n of 1, and even more questionable when the research subject is the researcher. However, this may be a valid and long overdue approach in CBT, with the potential to reduce stigmatization of patients and to increase therapist personal development and engagement with theory. This case study may be usefully called a ‘haptic autoethnography’ due to its use of autobiographical data and personal experience as a way of increasing understanding of theory, and theory to understand the self. Generalization of personal experience is not unusual in subjectivist writing and research (e.g. Anderson, Reference Anderson2006; Putri et al., Reference Putri, Poerwandari and Rusli2018).
Systematic reflection is hypothesized as the route by which expert therapists elaborate their declarative and procedural knowledge (e.g. Bennett-Levy, Reference Bennett-Levy2006). Subjectivist research and writing may provide a modality by which CBT therapists can use their SP/SR experiences as valid research material. Experts can elaborate their knowledge through SP/SR and write them up as ‘haptic autoethnographic case studies’. Doing so can help to disseminate knowledge, which would otherwise be lost.
Writers of SP/SR case studies or ‘haptic autoethnographies’ may need to be aware of the limitations of their work, including the representativeness of their own observations and recollections. For example, it was challenging for me to avoid contaminating or being contaminated by the process of reflection. However, this is not dissimilar to a research participant tasked with self-monitoring to feedback to a researcher. This is an uncomfortable process involving self-exposure, vulnerability and the potential for offending others who may be identifiable in the writing. Self-censorship is therefore a threat to honesty and validity. For ethical purposes, it may be necessary to seek permission from those who may be recognizable in the writing.
Conclusions
This personal case study, which may be called a ‘haptic’ autoethnography, is not standard autoethnography but borrows heavily from it. It is, however, not dissimilar to others (e.g. Putri et al., Reference Putri, Poerwandari and Rusli2018). The marrying of SP/SR and autoethnographic technique provides a potentially valid research methodology for SP/SR. This may help to influence the current position, in which most CBT therapists have little or no experience of what they practise clinically, which is akin to a great chef whose recipe is enjoyed by many but which he/she has never tasted. The approach demonstrated here may allow the CBT chef to taste his/her recipe and perhaps, improve it.
Author ORCID
Craig Chigwedere 0000-0003-1081-246X
Acknowledgements
The author would like to acknowledge his gratitude to Dr Alec Grant for his autoethnography influence, Dr Richard Thwaites and Dr Brian Fitzmaurice for their support, and my colleagues and mentors and Professor Gary Donohoe and Professor James Bennett-Levy.
Financial support
No financial support was received for this study.
Conflicts of interest
The author, Dr Craig Chigwedere, has no conflicts of interest with respect to this work.
Ethical statement
The author has abided by the Ethical Principles of Psychologists and Code of Conduct as set out by the APA. No ethical approval was needed: the treatments were delivered within routine clinical practice and the clinical cases consented for anonymized details of their therapy to be included.
Key practice points
(1) This personal case study is an initial demonstration of how SP/SR practice can be continued by experienced CBT therapists post-training.
(2) Given that SP/SR is subjectivist and its research evidence is positivist, a subjective methodology for writing and publishing personal insights gained, as well as the influence on theory, is timely.
(3) Borrowing from autoethnography can enhance the influence and dissemination of learning from SP/SR.
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