A lot, actually.

But first, let me summarize some of the major similarities between cognitive-perceptual (CP) therapy and other major therapies. CP therapy is a type of insight-oriented therapy, designed to help clients achieve self-understanding and self-awareness. It is also like most behavioral techniques in that it is structured and that it aims to produce new behaviors--or what CPers think of as more adaptive patterns of responding. Like humanistic and Rogerian therapists, CP practitioners believe that the answers to a client's problems are known to the client; the therapist's role is to help the client discover what s/he already knows. We are also interested in maladaptive thinking patterns, like cognitive therapists, but we tend to look at these as driven by inappropriate attitudes, which can be uncovered in memories. And like neurolinguistic practitioners, we are interested in subvocalization phenomena like the so-called 'critical parent' in depressed clients, which erodes self esteem. But what are the differences?

CP practitioners maintain a strong allegiance to insight and self awareness but believe that insight constitutes just the first step to changing one's patterns (which rarely happens by itself). In that sense, CP therapy is committed not just to damping down Axis I symptoms (depression, anxiety)--the focus of managed care-- but rather to honing in on the dysfunctional patterns that generate them. Most people are not troubled because they are unaware; they are upset because their patterns are producing results they don't want. For instance, they can't hold a job or their relationships don't work or they are anxious all the time. But most of us are not keen about changing our patterns, which have become fused with our self identity, unless we can see that something else is going to work better and ultimately make us less miserable. Worse, many of us can't even see what is wrong about the alleged defective pattern because we are too close to the problem. What helps us get the proper perspective is memory work. Traditional insight oriented therapy was often able to do this, after a fashion, if the client was reconciled to slow results and the therapist was highly skilled at memory interpretation (many are not in my experience). Thus, therapy was largely a hit or miss affair which, minimally, took a long time, in part because it often took a long time for the pertinent memories to emerge.

What is innovative about CP therapy is its aggressiveness in identifying the pertinent memories early in therapy and in involving the client in this process by requesting 'homework'. There is no compelling reason for therapy to take place only in the consultation room, but therapists have been historically reluctant to ask clients to work outside sessions, perhaps because of their own confusion about what clients can in fact do on their own. After a typical intake in which we look at the presenting problem and/or symptoms, and the onset of same, we ask our clients to take home an Early Memories Procedure (EMP) to complete before the second session. By the start of the second session, clients have reviewed and described in the EMP 21 life experiences that almost invariably speak to the etiology of their presenting problem. In the second session, the therapist interprets the key memories using two standardized techniques--the precis and process interpretation. These standardized techniques help therapists arrive at similar impressions as they attempt to understand the presenting problem; from a statistical perspective, they were devised to increase reliability and, ultimately, validity. On a 7 point scale, four groups of women prisoners in a recent study rated the EMP on its degree of helpfulness as 6.6 on average--virtually a perfect score. Over the years, my out-patients have provided similar ratings, as have professionals at workshops who have been taught to use the EMP. What the EMP does--better than any other instrument I have ever experienced--is promote self-awareness and perspective. Clients truly understand themselves and how they came to be in this place in their lives. If they don't, then the second session--where I interpret the EMP in session--usually fleshes in the details. Not that I see myself as a brilliant clinician--the EMP asks great questions and provides most of the information we need to get therapy off to a running start. No clinician is particularly good without good information to start with.

What makes the EMP so innovative? First, believe it or not, no one had ever previously sought to assess the whole of autobiographical memory, at least the part that has clinical relevance. When I was an intern at Duke Hospital, my supervisors looked at me quizzically when I told them I requested my clients' earliest memories. They were concerned that my probing such matters might trigger a psychotic episode, not because others had that experience but for theoretical reasons. Freud's psychoanalytic theory suggested such could happen. So following the classic medical principle, "first do no harm", this door was shut and locked and the arena avoided. Thus, no one had ever done anything like that before, I was told. Many years later, I tend to view my graduate school experiences as analogous to those of Columbus. As you may recall, this explorer was told by his colleagues that his plan to sail to the new world was insane because everyone knew the world to be flat and therefore such ventures would surely end in disaster with his ship sailing over the edge of the earth. Fortunately, both dire warnings were grounded in theoretical misunderstandings.

From a therapy perspective, however, this is a small point in a long game. As CP people see it, the larger problems with classical insight oriented psychotherapy are these:

• too much time is spent trying to understand the problem and how it came to be, and too little time is spend trying to figure out what to do about it. In fact, the trained insight oriented psychotherapist spends so much time and energy trying to uncover "the truth" that there is little left to figure out what to do about it after it is uncovered. As the CP theorist sees it, the balance between uncovering and fixing the problem is skewed in the wrong direction. The answers which I received to this objection from analysts were as follows: Either 'we are not in the business to fix problems, we are in the business to help patients learn about themselves'; or 'once people understand themselves and have the freed up energy available that therapy provides, they will discover on their own the path they need to follow'. In my experience, if the latter happens at all, it takes far too much time.



• far too much time is also spent doing therapy in the therapy hour and thus creating an unnecessary dependence on the therapist; as a result clients spend too little time working on their own outside the therapy hour. Therapy as I see it is a vibrant living process, something that should be happening 24 hours a day (dreamwork counts also). The therapist should function more like a consultant: "It looks like 'X' is still giving you a problem--would you be willing to give 'Y' a try?". The side effect of doing almost all the work in the therapy hour is that an imbalance is created between what the therapist is doing and what the client does. The greater the imbalance, the more severe the dependency. A parallel argument is often raised in the area of education, with one side arguing for the efficacy of homework and the other maintaining that 'homework' should be done at school. In my opinion therapy can be done much faster and with more satisfactory results if we encourage clients to use their life experiences as if they were going to a college lab course. For ultimately, the final test of what is done within the therapy hour is whether it can be replicated under far less favorable conditions in the real world, which is where the nastiest problems are!

Like Rogerians and humanistic practitioners, CP theorists have enormous respect for our clients. Rogerians believe that the clients know the answer to their problems. The adept practitioner merely helps them rediscover what they knew all along. The Rogerian accomplishes this goal primarily by reflective listening--"I'm hearing that you feel 'x' when.... Is that right?" This technique is extremely useful, but the CP therapist believes that the need for overusing this technique can be by-passed through a clearer understanding of the presenting problem via memory work.

Without access to critical life experiences that bear on the presenting problem, the clinician can be analogized to a blind folded worker with heavy work gloves rummaging through a junk box for a critical component. The better skilled clinician through a process of well considered inferences is more likely to stumble across the correct solution with fewer errors than a clinician with lesser talent. But the larger question is, "why use a blindfold and heavy work gloves?" Why put yourself in that sort of disadvantage? Why not just request the memories you need to do the job right in the first place?

I conceptualize the CP method as the next generation of insight oriented psychotherapy. If automobiles can be improved, why not therapies? The CP model combines assessment and therapy seamlessly. It helps the insight oriented therapist by providing the kind of information that is critical from the second session. It encourages clients to become active in their own therapy, which is what they are eventually going to have to do anyway after they terminate. So why not do it from the beginning? And it helps to redress structural imbalances in the therapy relationship that have been indigenous to classical insight oriented therapy. If you haven't already looked into CP therapy, I hope you will. I think you'll gain from it, whether as a practitioner or client!