Topic 3: The Practice of CBT – Therapeutic Relationship & Session Structure {by 9/21}

There are multiple readings due this week (J. Beck – 3 Chapters; Wright et al. – 2 Chapters).  For this discussion, share at least two main thoughts: (1) What is your understanding of the therapeutic relationship in CBT (include collaborative empiricism in your discussion)?  (2) Why is it important to have session structure for effective CBT?  Your original post should be posted by the beginning of class 9/21.  Have your two replies posted no later than 9/23.  *Please remember to click the “reply” button when posting a reply.  This makes it easier for the reader to follow the blog postings.

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42 Comments (+add yours?)

  1. Matthew Collin
    Sep 17, 2017 @ 12:42:32

    (1) Collaborative Empiricism:
    The way I understand the concept of the therapeutic alliance (or collaborative empiricism) in CBT is that a therapist needs all the common factors that almost every orientation of therapy is supposed to exhibit. These are things such as accurate empathy, displays of warmth, and genuineness. What is so great about CBT is that there are added expectations that a therapist is supposed to conduct in order to cooperate a good therapeutic alliance. Wright, Basco and Thase describe this is the CBT clinician as having a collective sense of responsibility for goals, and overall outcome of the patients (or clients) success. I believe this adds an extra component – at least at face value- that strengthens the therapeutic relationship.
    Another component that I thought was exceptionally helpful to understand the therapeutic reliance between CBT clinician and client is the role of coaching. I like CBT because it doesn’t lend sole responsibility of the therapy process on the clinician, but more of a navigator helping guide someone through the fog of irrational emotions, thoughts, and beliefs. In the book, there are a few vignettes that show the clinician interacting with a client using words of empathy, understanding, and genuineness, but also adding another component of educating the client on how he/she may be able to perceive the events that happened in his/her life differently (the education is obviously using CBT terminology). I do think that this is a distinctive feature of CBT that gives a positive effect on the bond between client and clinician.
    A final thought I want to mention is that I enjoyed how Wright, Basco and Thase mention humor as an added component of therapy. Obviously, as with most words spoken by a clinician, need to be calculated and accurately implemented. This is exceptionally important when injecting humor into a therapy session. I think that the use of humor can be helpful to show how irrational one’s own thoughts can be, and the idea of a client laughing in the face of the things that cause him/her so much pain appears to be therapeutic. A clinician who can accurately and intuitively implement humor into a therapy session could give an added, positive effect on the therapeutic alliance.
    Contrary to what people say about CBT clinicians, I do believe that the orientation lends itself to creating stronger therapeutic alliances than other orientations based on the factors described earlier. Although CBT is based on empirical evidence, it doesn’t mean that a clinician needs to take on the role of a researcher and scientist in a therapy session. I think all clinicians needs to take on the role of a coach (not a little league coach. Most of those guys show inaccurate displays of emotion). A CBT therapist must be intuitive enough to know what to say, when to say it, and ways he/she can incorporate the CBT paradigm into therapy.

    (2) Structure in therapy:
    Judy Beck goes over a lot of semantic information that needs to be gathered on session one, and sessions that proceed it, but the most I got from her readings was that a clinician and client need to stay focused on the problem at hand. This is important to get a problem, thought, core belief, or emotional response resolved and managed.
    Beck goes over how much education goes into the process of CBT, and organization, and an agenda can help push through this process in a timely manner, and aid the client at understanding the model of CBT. CBT is a dense therapy compacted with tons of information. A CBT clinician needs to always be prepared as to what the next step has to be in therapy. Preparation is the best way to gather the information you need in order to make a case conceptualization of a client’s presenting issue, and to create a treatment plan that can be efficacious.
    Another reason why structure in therapy is important is because clients may only have a select amount of session with the therapist. I’m not suggesting a unified protocol is the answer to good structured therapy, but a client may get off track, or avoiding certain topics and it’s important to rein them back into the conversations that need to be had. For instance, if a depressed client went through a crisis before the upcoming therapy session and they want to discuss it, it is important for the therapist to be responsive to that; however, a clinician needs to fit the clients thoughts, emotions, and beliefs about the event into the fray of the overall problem he/she came to therapy to address. Therapy needs to be structured, but it by no means needs to be scripted. Although it’s good to be proactive as a therapist, it is also important to quickly react and refocus.

    Reply

    • Venessa Wiafe
      Sep 17, 2017 @ 13:57:38

      Hi Matt, I really liked how you touched upon the fact that clients may only have a select amount of sessions with their therapist. Time is extremely important when it comes to therapuetic sessions. CBT, to my understanding, is rather short and there is only so much time available to therapy for the client. It is indeed important to have that in mind as a therapist so that all goals that are being set towards change for the client can occur. Time should be utilized wisely during the sessions and it is important, like you mentioned, to bring the topic being discussed during therapy back to life whenever the client may go on a tangent for a while. I also liked how you stated that therapy should be structured, but not exactly scripted. Yes, structure should be followed during therapy but it is also important for the therapist to listen fully to the client. Even if the client wants to disclose something that wasn’t suppose to be discussed during therapy during a specific day, but is related to the therapeutic relationship , for instance, or even related to the client’s thoughts and behaviors, the therapist should allow the client to discuss it. Not every session will be ran perfectly, but forming structure will definitely help it run with effectivenes.

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    • Chiara Nottie
      Sep 23, 2017 @ 11:18:36

      Hey Matt,
      I also like CBT’s ideation of the therapeutic relationship. CBT believes that the point of an alliance between clinician and client is not to just keep the client coming back for more sessions but, in order to make treatment progress, which should be the true aim of therapy. CBT, unlike other forms of therapy seems to really attempt a collaborative practice between clinicians and clients. As we read, the clients are the experts of their own lives, so it’s odd to think some fields of therapy do not take as much of a collaborative approach towards treatment. In other relationships, there’s supposedly a more or less equal given and take between parties that enforces the relationship’s continued existence. I think in professional fields such as therapy, medicine, law, business (etc.) collaboration between provider and consumer would only make sense too.

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      • Lindsey
        Sep 24, 2017 @ 07:50:45

        Hi Chiara, I enjoyed reading your comments for question 2… “Supposedly, during an intake session a clinician will have a conceptualization of the case and will want to form a treatment plan.” It is true that you can only get so much information during intake… One concern I have as I enter the field as a new therapist is how to set and maintain those boundaries appropriately as to prevent (or stop) tangents -word vomit- so we can maintain focus throughout the session. It requires tact and professional experience to handle those situations appropriately because you don’t want to accidentally make the client feel invalidated. Then again, some of those tangents might provide additional insights about the client’s perception of self/others/world. It’s a delicate balance but no less, I think it is important to keep in mind that the clinician’s cognitive conceptualization is organic and evolving because things do come up that might require tweaking of the treatment plan. The theme is still the same: the situation does not directly determine how a client feels or what they do. A person’s emotional response to one situation is likely the same applied thinking patterns to another situation. Even though a clinician might not learn everything about the client, they/we will hopefully be skilled enough to pinpoint their general thinking patterns and core beliefs.

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  2. Venessa Wiafe
    Sep 17, 2017 @ 13:47:26

    1. It is extremely vital to make sure a genuinely and positive therapeutic relationship is established between the therapist and the client throughout the the course of therapy sessions. The tone of the therapeutic relationship starts as soon as the client walks in for his first session and first impressions are everything. During the therapist’s very first encounter with the client, it is vital for the therapist to get a vivid understanding of the client. The therapist should acknowledge the client’s difficulties in life so that the therapist can get a sense of the client and have a chance to kind of place his feet in the client’s shoes and be able to undertand what he is going through. The therapist and the client should be working collectively, as a team during therapy, as it can it can promote an effective bond between the two. The therapist should display certain characteristics before the client in therapy, such as being considerate, being straightforward and genuine, being empathetic, providing warmth, being nonjudgmental, being nice, being trustworthy, and providing unconditional positive regard. These characteristics can really assist a client with being able to feel comfortable with disclosing his issue(s) at hand and not having to feel bad about his current state in life. The client will feel accepted and supported by the therapist, regardless of what he has going on in his life or what he will disclose to the therapist. Going to therapy may be the first move the client has ever made in his life to receive help and it also may be the client’s first time diclosing personal information from his life, so it is vital for the therapist to give the client his undivided attention and listen actively. The client should be careful when utilizing humor during sessions as the client may perceive for instance, the therapist’s laughter, as an insult towards him. He may believe that the therapist find his issues at hand humourous, when it is painful for him to undergo. Even though the therapist is positioned as the one guiding the client towards treatment as being the coach in therapy, the client should also be a team player in the therapeutic relationship. The client is able to have a voice in therapy, so that he can work with the client towards a better life for him. Collaborative empiricism is one of the fundamental concepts of CBT. It is utilized during therapy in which the client and therapist are able to work together towards different aspects in therapy such as, altering maladaptive thinking and behaviors and replacing them with much healthy and adaptive forms of thinking processes and behavior, and formulating various ways for the client to deal with difficulties in a much more successful manner. Collaborative empiricism is able to determine if certain cognitions of a client are of good use and serve a good purpose or not by utilizing empirical evidence. Socratic questioning is also utilized in collaborative empiricism in aims to view the validity of cognitions. Socratic questioning can help identify irrational and counterproductive thoughts and behaviors, so that important adaptive changes and coping strategies can be implemented and put into practice to help the client. The therapist and client are also able to acknowledge that they are both held liable to producing good change in the client. The client isn’t alone in his unfortunate situation(s). The client and therapist are both able to set goals and maintain focus on them so that they can be accomplished. The therapist and client are able to eradicate irrational thoughts and behaviors by forming specific strategies that will enable the client to cope with the situation better.

    2. Structure serves as having great importance when it comes to CBT effectiveness. The therapist should have a plan in mind before moving into what he wants to do in CBT. Without formulating plans, being organized, and following structured steps, confusion can come into play and it can be extremely difficult for CBT to run smoothly and effectively for the client. Structure helps with directing therapy and without direction, change can’t occur. Establishing structure in CBT helps to make sure that the goals being set can be accomplished during therapy and knowing how to accomplish these goals is important to acknowledge so that it can actually be possible. A therapist shouldn’t try to complete all tasks for a client during CBT at once . It will be too much for the therapist and even more importantly, too hard on the client seeking help. Everything should be done in a step by step basis though goal setting, agenda setting, symptom checking, bridging sessions, feedback provision, pacing sessions, and assigning homework throughout therapy for the client. The client should be able to feel comfortable and positive that his goals can be met and with structure being formed, that can definitely get the job done. The therapist leads the way when it comes to structure, so that the client can also help himself with being able to have a sense of control over his problems and also being able to formulate change with the therapist. Having structure during the earlier CBT sessions is important to do because as sessions move along, more information about the client is provided and it can become difficult for the therapist to adhere to all of the vital information without structure being present. The therapist can run into issues when trying to recall everything that was said during therapy sessions. It is salient for the therapist to comprehend everything the client discloses in the beginning as it plays a huge role in knowing what to do for the client towards the middle and end of therapy. During the beginning, the client is finding out what the client is about , what issues are occurring in his life, and what his thoughts and behaviors due to these issues are. Without acknowledging these important factors, the therapist won’t be able to help bring about change in the client’s life. Structure helps the therapist as well as the client to remain in control and guide them in knowing how to approach everything. Structure will pave the way for the therapeutic relationship to be formed in the best way possible. It can also allow the therapist to utilize his skills in CBT accurately, acknowledge all overt and covert issues in the client’s life, keep the client and therapist focused, and help bring the client to recovery from all of his issues and symptoms so that he can live an adaptive life from effective change being established during the CBT sessions.

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    • Alana Kearney
      Sep 21, 2017 @ 15:13:09

      Hey Venessa! You make some great points about the importance of keeping structure within CBT therapy sessions. It is difficult to ask therapists to keep track of so many things at once like trying to listen, interpret, plan, and teach the client all at once. Although structure is, as you mention, salient for good therapy, I think the authors do a good job in also reminding us readers that there is also an emphasis on flexibility within the structure. Even though none of the steps should be missed in any given session, it may be difficult to talk about every issue that may arise at the beginning of the session by the end of the session. The structure allows for guidance, but flexibility accounts for the unexpected circumstances in therapy.

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  3. Julie Crantz
    Sep 19, 2017 @ 18:06:31

    1. The therapeutic relationship in CBT is a working alliance between the therapist and client that is collaborative, genuine, and results-oriented. The therapist demonstrates warmth, flexibility, empathy, and positive regard toward the client. Within the therapeutic relationship, the therapist is sensitive, compassionate, and equanimous while discussing emotive subject matter with the client (Wright, Basco, & Thase, 2006). Although the therapeutic relationship is extremely important in CBT, it is not regarded to be the primary vehicle for change as seen with other types of psychotherapy. A specific feature of the therapeutic relationship in CBT is collaborative empiricism. This refers to the therapist and client working together to pinpoint troublesome thoughts and behaviors and examining them empirically for validity. The therapist and client collaborate by using goal-setting, agendas, feedback, and CBT methods. The collaborative empiricism within the therapeutic relationship helps to advance cognitive and behavioral change for the client. The therapist acts as a teacher and coach for the client, using humor when appropriate. The therapist remains cognizant of the client’s situational issues, sociocultural issues, diagnosis, and symptoms to maximize efficacy during therapy. The therapist’s ability to manage possible transference and countertransference reactions is another important component of the therapeutic relationship (Wright, Basco, & Thase, 2006).

    2. An important aspect of CBT is implementing structure within therapy sessions. Structure provides direction for the course of therapy, and helps to facilitate change. Formulating goals, setting an agenda, evaluating symptoms, providing feedback, using appropriate timing during sessions, and assigning homework are vital elements to creating a sound structure within therapy. Designing therapy sessions to have order and focus helps to advance learning for the client. Education is a critical facet in therapy that is supported by structure (Wright, Basco, & Thase, 2006). A therapist adapts structuring to the phase of treatment with the client. For example, within the early phases of treatment, psychoeducation will be incorporated to teach a client about the cognitive model along with basic CBT concepts and methods. In the middle phase of treatment, there will be emphasis on expanding the use of thought records and developing new homework assignments. The late phase of treatment will include relapse prevention work. Each phase will build upon the next and will continue with an organized approach to keep the therapist and client on target with meeting goals. It is through the use of structure and education that a client will be helped with learning and establishing valuable and adaptive coping skills (Wright, Basco, & Thase, 2006).

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    • Olivia Grella
      Sep 20, 2017 @ 16:47:27

      Hi Julie, I like how you mentioned that structuring sessions can help educate or teach clients as well. When talking about structure, it can sometimes be seen as just a benefit for the therapist so they don’t have to worry about forgetting to do something. Structure can be extremely beneficial to the client because those teaching moments are being built into the session. This way the time is appropriately spent teaching the clients these skills to move on within therapy and get better.

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    • Chiara Nottie
      Sep 23, 2017 @ 11:24:58

      Hey Julie,
      You summarized structure to CBT therapy sessions really well (you should’ve wrote the chapter about it). I think mentioning the breakdown of phases to treatment with early, middle, and late was important to mention. As we read there isn’t only a structure to individual sessions, but to the treatment timeline. I think the flexibility in combination to CBT’s structure helps it be such a successful field of therapy. Having a game plan and actually identified areas of where work should be down is necessary for progress, but I also like how CBT recognizes that not all cases are alike, and that certain stages of sessions may need to be switched around. The overall guided expectation of what should be accomplished in early phases of therapy vs middle or late helps keep an organization to the flexibility. Therefore progress can stay on track through multiple avenues.

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  4. Olivia Grella
    Sep 20, 2017 @ 08:25:49

    In all the readings for this week, there was great emphasis placed on how important the therapeutic relationship is in CBT and how building a positive relationship from the start is extremely important. However, like mentioned in one of the chapters in Judy Beck’s book, one common misconception is that CBT is done in an emotionless, mechanical way. This is completely untrue because a solid and genuine therapeutic relationship is essential to continue on in therapy and be successful. For one, as therapy continues the therapist is going to start challenging those automatic thoughts and core belief that the client has. Challenging these thoughts and beliefs without a positive relationship can be extremely detrimental. It could lead to negative treatment outcomes and may not be able to be made up for in later sessions. Therefore, building rapport from the start will lead to a good relationship plus positive treatment outcomes. Also, therapists will elicit feedback from the client, especially during the early sessions to strengthen that alliance. This way they can know what the client is thinking about the therapy and if they have any negative views. This way if there is, changes can be made sooner rather than later to accommodate these negative feelings they are having.
    In CBT, the therapeutic relationship is often referred to as collaborative empiricism. This emphases how CBT is a research based treatment because the client and therapist will work together to create hypotheses based on the client’s thoughts and beliefs. Then they will test these hypotheses to teach the client that maybe these maladaptive thoughts they’re having actually aren’t valid or something else along those lines that the therapist is trying to help the client accomplish. Collaborative empiricism incorporates how the therapeutic relationship in CBT is action oriented and also creative. Collaborative empiricism is change focused to help the clients improve their lives and the ways that they go about doing this vary based on the client and what they are comfortable with.
    Like previously stated, a common misconception is that CBT therapists do therapy in such a structured way that it doesn’t lend itself to a positive therapeutic relationship. CBT is very structured, but doesn’t mean that the therapeutic relationship is emphasized any less. The session structure for CBT is very effective and can give clients who are coming to therapy for the first time some comfort about what to expect. Also, CBT is time-limited and a lot needs to be covered in a relatively short amount of sessions. The structure not only makes the sessions flow together, but also helps accommodate for this. The structure of sessions is also influenced by the client. For example, when planning the agenda, they pick which topic is of most importance to them at that moment. However, occasionally the therapist will direct them in a different way if there is an issue more pressing that they do not pick. This stays consistent throughout treatment with slight changes being made as the client becomes more skilled at identifying their automatic thoughts and core beliefs or when termination is coming and the client needs to be prepared for this and given skills to help them avoid relapse. Overall, the structure makes treatment effective because the client and therapist are still working together, but in a way that maximizes the time that they have together.

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    • Liisa Biltcliffe
      Sep 22, 2017 @ 09:28:03

      Olivia, I agree with you (and mentioned in my post) about how the therapeutic alliance is so important in CBT and that there is a common misconception about CBT therapists being cold or mechanical. I like how you pointed out what Dr. V. said in class this week (although this post was prior to his statement) about how building rapport can lead to positive treatment outcomes. I also like how you hit the nail on the head about cognitive empiricism and the scientific part of it.

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    • Julie Crantz
      Sep 22, 2017 @ 17:05:48

      Hi Olivia,
      You mention a common misconception about how CBT is thought to be handled in an emotionless, mechanical way. I appreciate you bringing this up as it really couldn’t be farther from the truth. A positive therapeutic relationship is of great importance with CBT and the therapist showing genuine empathy and compassion toward the client is critical. The work that is done in CBT requires a strong therapeutic alliance where the client will trust the therapist. CBT really does have much to offer clients as they not only have a caring therapist in their corner, but also have someone that works with them and teaches them how to investigate negative automatic thoughts and cognitive distortions, bringing awareness to more adaptive ways of thinking and behaving. The structure found in CBT also empowers both the therapist and client to work together as a team, bringing about positive change.

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  5. Sarah Hine
    Sep 20, 2017 @ 10:56:26

    1. The therapeutic relationship in CBT is a critical component to the therapeutic process. In our readings, it was described as “collaborative empiricism”, a process that involves active input and involvement from both client and therapist in tackling problems and coming up with solutions. The therapist acts as the expert, but is approachable and flexible, viewed as a coach or a teacher, always with the intent of working with the client to achieve goals. The client is being educated by the therapist, and is using this information combined with their own experience to work on goals and problem solving. Passive involvement on the client’s part does not allow for success in CBT, so it is important that his relationship with his therapist allows him to feel encouraged and willing to contribute. A positive relationship between the client and the therapist is often linked to success in therapy, so the therapist must focus on strengthening the relationship with the client throughout sessions. Part of this process involves including the client in the treatment planning process, ensuring that their feedback is heard and their ideas are incorporated into planning. This ensures that the client feels involved and that the therapist values his feedback. When a therapist takes time to get to know her client, she will be able to vary her style or responses to match her understanding of the client. A trusting and cooperative relationship allows for the client to feel understood and valued, and empowered to be engaged in treatment. Any positive or negative aspects of the therapeutic relationship can be addressed in therapy as a way to problem solve and practice CBT. Instances of transference may be addressed in therapy in order to strengthen the therapeutic relationship and raise awareness of distorted thoughts about other relationships. This also allows for practice in relational problem solving that the client can apply outside of therapy. Therapists must also be aware of instances of countertransference, and be willing and able to address any personal issues that may be hindering their ability to work with a certain client. Any unresolved issues in the therapeutic relationship have the potential to lead to negative outcomes in therapy, so it is important the therapist is able to identify and address these concerns appropriately.

    2. Session structure allows for a cooperative environment throughout therapy that meets the client’s needs and ensures that they are being treated to the fullest potential. Having structured sessions allows for the therapist and client to work collaboratively and to be on the same page. It provides a sense of stability for the client, who, especially in beginning sessions, may be unsure of what to expect. It also provides a sense of stability for the client throughout therapy, knowing generally what to expect and knowing that the therapist is involved and is putting attention and care into the details of each meeting. For the therapist, having a set structure eliminates some uncertainty about what to say or do during therapy. Because they have already planned generally what the session will look like, they can put more time and attention into the content of therapy. As a beginning therapist, session structure is appealing because it gives me a foundation to work with and will allow me to turn my focus on the client rather than worrying over the practical issues of what to do next.
    CBT provides a general format for each session, and each part of this format is important in ensuring that the client is actually receiving help and is engaged in therapy. By setting an agenda at the beginning of each session, the therapist and client can be collaboratively involved in the process of structuring that individual session, ensuring that important topics or goals are addressed and eliminating anything that is no longer relevant. CBT is typically brief, so it is important to stay focused during each session in order to meet goals and work toward effective problem solving. It is important for the therapist to keep the client (and herself) on task and focused on the agenda, even if this means politely interrupting a client who may be sidetracked (or holding off on sharing her own thoughts until a later time). Setting and revising goals are also included in every session. These goals are critical in shaping the remainder of the session and in shaping the outcome of therapy. They give the client and the therapist objectives to focus on and to measure. The remainder of the session focuses on problem solving and education related to goals, setting homework, and review and feedback about that session. Homework assignments are important to include because they incorporate these discussions in therapy to the client’s life outside of therapy, and because they can be used in following sessions as methods of assessing progress and measuring goals. Having an opportunity to provide feedback and review the session allows for client reflection and for any concerns or confusion to be addressed. Regularly including assessments at the beginning and end of sessions and receiving feedback about therapy ensures that the client’s progress is being measured and that therapy is being effective. Each of these aspects are important parts of CBT, and they all work together to ensure client’s problems and symptoms are being addressed. Issues can arise when sessions have no structure or too much structure, so it is important for therapists to find a balance while finding a way to incorporate their own style and respect the needs of the client. Structure ensures that these individual sessions flow and each part is connected and makes sense. Session structure also allows for the client and therapist to focus on the big picture, connecting each session and ensuring that they relate to one another in order to meet overarching goals of therapy for that client. When each session is addressing relevant goals and tracking progress, and sessions feel connected and relevant to the problems at hand, therapy can be effective.

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    • Olivia Grella
      Sep 20, 2017 @ 16:57:07

      Hi Sarah, when talking about collaborative empiricism you made a comment on how the therapist acts like an expert, but is still someone that is approachable and flexible to making necessary changes. This was a connection that I previously didn’t make at first, but reading your post made this click in my mind. The therapist has all this knowledge and skills available to instruct the client on how to make change, but if they are unable to meet the client where they are at or shift the way in how they approach something than change isn’t going to made.

      Reply

    • Julie Crantz
      Sep 22, 2017 @ 17:04:17

      Hi Sarah,
      I appreciate you mentioning the importance of creating stability in session with a client through the use of structure. Such a great point to make! Taking the initiative to go into therapy can be very daunting for a client. There may be many unknowns for the client and providing a stable environment with structured sessions certainly provides a solid foundation for building a positive therapeutic alliance. You also mention that structure removes some uncertainty of what to say or do during session for the therapist, which is another important point. Structure also benefits the therapist in many ways to allow for providing the best possible course of treatment, as there is less worry of how to organize each session.

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  6. Liisa Biltcliffe
    Sep 20, 2017 @ 12:40:13

    My understanding of the therapeutic relationship in CBT is that it is of utmost importance. The therapeutic alliance needs to include Rogerian aspects such as genuineness, positive regard, and empathy. As it states in the readings, CBT therapy can sometimes be misconstrued as cold and uncaring; however, this is not the case. It says in Wright (2006) that the key to empathy is genuineness and that a genuine CBT therapist will give constructive feedback but not hide the truth. CBT is based on collaborative empiricism, which is the client and therapist working together to set goals, share feedback, and work together to make the CBT model work. In addition, my understanding of it is that it is client and therapist working together to make the CBT model work efficiently for the client. I like that Wright incorporates humor because I feel as if this is important in some cases when used appropriately. He also mentions flexibility and I feel that this is quite important because each client is different and even though diagnoses may be the same in different client, technically they are not the same because of the fact that each client is unique. Symptoms may manifest differently and similar to raising children, what may work for one client may not work for another. What I found interesting in Wright’s book was under “sociocultural issues” it says to be on the watch for biases even in paintings/pictures on the walls and magazines on the tables. I had not thought of those things. It was definitely eye-opening. For me, the therapeutic alliance is the foundation on which you build the rest of the CBT relationship. Without a solid therapeutic alliance, the rest of it will not work.

    Session structure is important in CBT for a number of reasons. One reason is that it helps to keep the client and therapist on track and reaching towards the client’s goals. It also shows along the way the progress the client is making in a structured manner that is easily grasped and proves that CBT is working. In other words, it provides hope for the client that things are getting or will get better. Another reason session structure is important is because it provides a template for the clients so that when they are at home, they can utilize these templates themselves and not have to rely solely on the therapist. One of the main goals of CBT is to have the client feel better and leave therapy with the skills to manage problems on his or her own as they arise. Feedback is an important part of session structure and it helps to strengthen the therapeutic alliance, which I feel is the foundation for CBT to work effectively. It states in Wright (2006) that pacing is also another important aspect of session structure. Pacing the sessions so that they are goal- and problem-oriented is important. This is so clients can feel as if they are making progress and it will give them some hope that they will get better. Psychoeducation helps clients to learn the skills so that they can take those skills and utilize them on their own. In addition, this helps to reduce the risk of relapse.

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    • Venessa Wiafe
      Sep 22, 2017 @ 15:05:03

      Hi Liisa, I really liked how you added that feedback is a salient aspect of CBT’s structure. I honestly didn’t realize how important feedback was until yesterday’s class as well as right now after reading your discussion post. I knew it was a segment of therapy, but I now acknowledge the fact that feedback should be asked for. It is beneficial to follow a set structure when helping a client in CBT in order to stay organized, on task, and make sure that the client’s needs are being met towards treatment. However, it is also vital to be able to find out if the therapist is working well with the client and making ends meet for him. Feedback should be offered after every session, so that the therapist doesn’t ask for feedback during the initial intake session, for instance, and not ask for feedback again until five sessions later. So much transpires during the early stages of therapy to even the middle stages and the client should be assessed every step of the way. This will make sure that the therapist and the client can be on the same page and the therapist can accommodate everything he needs appropriately. The therapist will be able to acknowledge what is and is not working for the client, which is vital because therapy is for the client to recover from his unfortunate life events.

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  7. Luke Gustavson
    Sep 20, 2017 @ 16:11:36

    1.
    The therapeutic relationship in CBT, to an individual lacking the knowledge of a CBT practitioner, seems to be a cold and mechanical affair. I even thought this myself some years back. However, as Beck and Wright, Basco, and Thase were quick to point out, the idea that CBT practitioners are as robots is a completely unfounded myth.
    Some important aspects of the therapeutic relationship within CBT is similar to many other therapeutic approaches, all having borrowed heavily from Rogerian work on the therapeutic relationship. Rogerian influence comes in the form of warmth, genuineness, and empathy to name a few. As such, practitioners are expected to be supportive of and honest with their clients. It is not enough to treat a client as a mechanic would treat a vehicle. Instead, CBT practitioners understand the need for warmth and genuineness and accurate empathy. Such a relationship facilitates psychotherapeutic interventions for the psychotherapist, functioning to create a social lubricant in rapport. However, the real benefit of these Rogerian ideas is that of the client: a warm, genuine therapeutic relationship assists the client in healing.
    The term most bandied about by the texts is collaborative empiricism, which refers to what many consider the true nature of the therapeutic relationship in CBT. This term defines this relationship as one of collaborators and experimenters, which is about as accurate as one can be. Instead of the relationship being driven by the therapist (psychoanalysis) or driven by the client (client-centered), CBT puts the focus on two individuals working together to formulate goals, set agenda items, give and receive feedback, and even generate homework assignments.
    Breaking it down a step further (for fun), collaborative empiricism likely refers to two steps in the process of CBT as well as the process overall. First, we know that the work in CBT is to target, understand the nature of, and correct faulty automatic thoughts and core beliefs, basically. The first step is obviously to understand and target faulty automatic thoughts, collaboratively, with both psychotherapist and client working together. For instance, agenda items are written with the client’s permission if the psychotherapist has an idea and clients will be asked if they think there is anything important to add.
    The empiricism comes from how the particular agenda items are approached, particularly the major priorities. A client is wholly encouraged by the psychotherapist to test their thoughts and beliefs with behavioral experiments and evidence-based examination, with the understanding that they use reason and logic to correct problems.
    Another facet of the CBT relationship is that the activity level of the psychotherapist is particularly high at the beginning of therapy and relatively low at the cessation of therapy. This is due partially to a teacher-student theme of CBT. There is a fair amount of psychoeducation in CBT as we expect clients to learn CBT techniques in order to be their own psychotherapists in the future. Accordingly, the psychotherapist spends much time in the earlier sessions teaching the methodology of CBT to the client. This reverses over time as the client becomes more proficient at CBT and takes on more responsibility for their treatment, such as setting the agenda and choosing what to tackle.

    2.
    In the shortest words available, session structure makes psychotherapy run smoothly. This really is the long and short of it, but there is a lot more to it. Structure in a session refers to how the session is laid out and performed, and in CBT this becomes particularly important. CBT packs a lot into a 45-50 minute psychotherapy session, and in order to make efficient use of your and the clients’ time, it is necessary to create a structure and plan and stick to them.
    Wright et al. go into quite a lot of detail about the usefulness of a structure and provide a decent template for the structure of a session for novice psychotherapists. In particular, they point to goal-and-agenda setting as two structural techniques that can particularly assist psychotherapy. Clear, concise goals that clients can meet allow for agenda items and homework assignments that are achievable and understandable. Agenda items similarly should be achievable in that session so as not to take up too much time. One of the problems Wright et al. mention is that some novice psychotherapists set up unclear agenda items that take too much time to resolve or fail to handle them in a timely manner. This is a pacing issue, where a novice psychotherapist has difficulty setting the speed of the session, which ultimately throws the structure out the window.
    Structure is similarly important as it creates a smooth order for a psychotherapy session with clear transitions between phases. If every session has a mood check, homework review, agenda setting, etc. then it becomes easier for the psychotherapist and client to get into a groove that can speed things along. This has the added benefit of ensuring there is no uncertainty as to what the day’s session is likely to entail (aside from handling items on the agenda) and that this predictability means the psychotherapist will not accidentally forget part of the session or order it improperly.
    This is not to say that a psychotherapist should rigidly adhere to a structure (or an agenda, in this case). There are times when it might be appropriate to discuss a problem not initially on the agenda or to add an item later. A client could be well into addressing one emotional issue when another, much more pressing, issue starts to rear its head, for example. In such, and other, cases, it behooves a psychotherapist to be flexible with their agenda and overall structure of the session. After all, it does not seem very useful to review an extremely suicidal client’s homework when there is a much more pressing matter to grapple with.

    Reply

    • Liisa Biltcliffe
      Sep 22, 2017 @ 09:42:53

      Luke, I really like how you broke down collaborative empiricism into specific steps explaining each along the way, making it more understandable. I also like how you explain session structure, breaking it down (once again) as well as incorporating flexibility into your explanation, because I feel that flexibility is so important.

      Reply

    • Matthew Collin
      Sep 23, 2017 @ 08:08:48

      Hi Luke,
      I think you did a great job on mentioning how CBT doesn’t have to be ridged. Sometimes I think this is where the myth of CBT being a alliance absent therapy probably stems from – it’s structure. I also like how you mentioned prioritization. For instance, if thoughts of suicide weren’t on the agenda for the day, but a client expresses thoughts as of this type of content, then it would be appropriate to immediately address those.

      Reply

  8. Noella Teylan-Cashman
    Sep 20, 2017 @ 16:34:33

    The optimal therapeutic relationship in CBT is one in which the client feels respected, supported and understood, while working in collaboration with the therapist to solve his/her problems and alleviate his/her distress. This type of rapport must be established before any progress can be made. As we have discussed many times in class—a person could be the most skilled CBT practitioner, but will not provide effective therapy to clients if a therapeutic relationship is not formed. Therapists can work on building this type of relationship by displaying accurate empathy, warmth, and genuineness to their clients. While this type of relationship can be seen in different forms of therapy (i.e. Rogerian Client Centered Therapy), the notion of “collaborative empiricism” is CBT specific. The term “collaborative” speaks to the mutual and cooperative manner in which the therapist and client set goals together, give and receive feedback, and integrate CBT practices into everyday life. As the main goal of therapy, clinicians and clients work together to pinpoint problematic cognitive distortions/maladaptive behavior patterns and formulate coping strategies. The term “empiricism” speaks to the practical approach emphasized in CBT. Viewing cognitive distortions and maladaptive behavior patterns in this practical manner helps clients realize the flaws in their thinking patterns and can lead to the development of more rational thought processes and positive behavior changes.

    It is very important to maintain a sense of structure throughout the course of CBT in order for therapy to be maximally effective. Structure is especially critical during beginning therapy sessions; creating an outline for treatment that the client can understand and follow will help him/her feel more at ease and optimistic. Additionally, structured sessions ensure that the client and clinician are able to prioritize issues that warrant the most attention. This promises that the client is receiving the most quality treatment in the limited number of sessions allotted for CBT. However, it is also notable that the level of structure varies throughout the course of CBT. Wright et al. (2006) note that sessions should be more structured in the beginning to help work through symptomology and develop coping skills. Towards the end of treatment, sessions should be increasingly less structured so that clients can reach a certain level of self-sufficiency and become “their own therapists.” From each of these readings, I have realized the importance of creating the ‘right’ amount of structure in sessions; clinicians should avoid rigidity and overbearingness, but still organize sessions in a sensible manner.

    Reply

    • Stephanie Welch
      Sep 22, 2017 @ 23:19:13

      Noella,
      I liked that you broke the definition of “collaborative empiricism” into two definitions. I think that that the separate definitions makes it easier to understand “collaborative empiricism”. While it is important to understand that the therapist and client work together, I think it is also important to understand the practicality of CBT. I feel like the “empiricism” in “collaborative empiricism” can be overlooked with the strong emphasis on the therapeutic alliance. You pointing out the difference between the two terms helped me to think more about “collaborative empiricism”.

      Reply

  9. shay
    Sep 20, 2017 @ 19:15:53

    My understanding of a therapeutic relationship is that the relationship is one of collaboration where the client and therapist both have an active role. The relationship is team-based, where the client and therapist work in tandem to accomplish goals. A CBT therapeutic relationship is not one-sided where the therapist talks at the client and the client just does what is told. A client is a proactive agent and very important to the process. CBT is characterized by collaborative empiricism, which aims to promote cognitive and behavioral change. From what I derived from the reading this week, collaborative empiricism seems to be about reciprocity and shared responsibility. Both the client and therapist work together to set goals, to communicate feedback, and to utilize CBT skills. Wright proposes that the main job of the relationship is to view cognitive distortions and unproductive behavioral patterns through an empirical lens that can reveal opportunities for rationality, symptomatic relief and personal effectiveness. I can conclude in my own words that the therapeutic relationship should work to challenge distorted thoughts as well as maladaptive behavior in order to make the person’s life more functional and enjoyable.
    So at this point, it is evident that the relationship involves both parties to work. A necessary challenge is one in which the therapist must work to gain the approval of the client. Therapy relies on this interaction, so a lot of pressure may fall on the therapist at first to form a strong connection with the client. This relationship is based on establishing trust and rapport with clients. The client should be met with accurate empathy, positive regard, warmth and genuineness. This is conveyed through open body language, eye contact, good summations, accurate restatements and head nods. In a successful interaction, the client will feel valued, respected and understood. The therapist maintains this relationship by promoting a warm environment, where the patient feels validated and empathized with. This relationship is worked at and improved throughout the whole process, not just upon the first few sessions.
    The relationship is of such significance because the positive alliances formed are correlated with more positive outcomes. This makes sense. A therapeutic relationship is unique in its own right, but it is a relationship nonetheless. Compared to say a relationship with a boyfriend or girlfriend, the truth still holds. The better the foundation of the relationship such as the cooperation and respect early on, the more likely the relationship will be durable and maybe long term. Of course in therapy it is not necessarily good if the relationship lasts long term, but a positive outcome in therapy may take the form of achieving treatment goals or acquiring coping skills. Either way, the relationship still plays in integral role in the success of trajectory of treatment.
    While responding to this inquiry, a question popped into my head; one that I couldn’t entirely answer myself. I’m curious as to what anyone thinks, do you think the relationship is 50/50, or do you think one party (either the therapist or the client) has more responsibility in the success of CBT? I would personally think a CBT therapist would lean towards 50/50, but if I had to bend in one direction I would say maybe it’s a 60/40 relationship, with the therapist holding a bit more of the responsibility as the expert.

    2) Generally in CBT, there is a structure that works well to produce successful results, especially for new therapists. In the beginning of a therapy session, the aims are to reestablish the therapeutic relationship and to collect data. You will review their charts, their treatment goals and homework assignments from the previous session. Next you will attend to the objectives or problems on the agenda. The patient will be taught relative cognitive, behavioral and problem solving skills. The therapist then may assign more homework for the next session and review what took place that day.
    Personally, I feel structure would also keep the therapist on track. Clients may have many presenting problems, but because of the limitations in number of sessions, the therapist and client may have to prioritize which problems are the more dominant ones that are essential to being treated. Having a schedule may help both client and therapist to be reminded of treatment goals and to stay on track during sessions. Getting off track can result in not going over homework assignments or forgetting about practicing exercises. If you tell the client in the session prior that you’ll be reviewing the homework and then the time comes and it’s forgotten, the client may have some negative resulting emotions. They may feel angered that you wasted their time or perhaps ignored. A therapist needs to follow through, just like a client is expected to follow through. Wright evens mentions that structure is important in staying focused on key problems. Being really structured can also assist with pacing. A therapist may begin to judge at what point/ or at which agenda item they should be on based on time.
    Additionally structure is important for the sake of efficiency. I think structure communicates to the patient that this is a professional setting, where time is of importance and is to be used diligently. I think having a sound structure might also communicate to the patient, in some sense, expertise and knowledge. Take for example if you have ever been to a seminar, lecture or even a meeting. If there are no fluid talking points or visuals or a conceptually solid flow, many of the attendees may feel the talker is unprepared and therefore unprofessional and unsure. This isn’t necessarily the message a therapist should want to send to a client. A therapist should instead desire to convey a sense of confidence and professionalism. This should begin as soon as the client walks through the doors.
    Structure is also important for consistency and comprehension. Most people, especially those who struggle with anxiety, are comforted by knowing what to expect. If a client has a clear idea of what the therapy session and course of treatment will look like, it is expected the client to be more comfortable proceeding with this assuredness. Having a clear concise direction also makes the process more understandable and valid to the clients participating. If they see the therapist’s vision, they may be more willing to partake in the experience.
    I do find value in structuring CBT, but based on last week’s post as well as Wright’s book, I do believe that flexibility is almost equally important. A monolithic one-size-all approach might not work for every client. A therapist has to recognize that though sessions should be structured, sometimes they may need to be sensitive and adjust based on situational factors that may come up. From personal experience, I know that having a schedule or predetermined agenda can be extremely helpful, and likewise comforting. However sometimes, the plan might need to be significantly readjusted based on the client. When I do home visits with the children with ASD, often they may be really moody or behavioral depending on their days, and I may not accomplish exactly what I had originally planned. I may have to limit the amount of time I expect them to attend to or engage with an activity. On the opposing end, tasks and discrete trails may take longer as I work through tantrums. Structure is great, but sometimes there needs to be some flexibility within that schedule.

    Reply

    • Luke Gustavson
      Sep 21, 2017 @ 13:35:21

      Hello Shay,

      I also share your curiosity about the share of responsibility with regard to the success of psychotherapy. I can see good arguments for 50/50 and 60/40 (therapist/client). Namely that, if this is collaborative, 50/50 holds that both are equivalent. As for the idea of expertise, 60/40 certainly accounts for that and shows that the psychotherapist’s education and training should mean they hold more responsibility for treatment succeeding.

      I find myself thinking of Wright et al.’s section of therapist activity levels in CBT – I forget the page. They mention that the therapist is more active in the earlier sessions and the client is more active in the later sessions. I believe this could be related to the concept of responsibility as well. For instance, in the earlier stages of psychotherapy we might see that increased activity is correlated with increased responsibility, thus for the first few sessions we might start at 70/30 (therapist/client) and slowly move the pendulum over to 30/70 (therapist/client) by the termination of psychotherapy.

      This conflicts with my belief that the client bears the ultimate responsibility in CBT provided the psychotherapy is conducted in ideal conditions by an ideal practitioner. After all, lasting change cannot occur without dedication and effort. In this case, I think it more appropriate to cast the psychotherapist’s responsibility as becoming facilitative in nature as therapy progresses toward termination. The psychotherapist still bears a heavy burden of responsibility in the relationship, to be sure, but I believe the client is ultimately responsible for the outcome. I am certainly not excusing poor psychotherapists, however. If a psychotherapist is unskilled or unable to build an appropriate rapport with their client, that outcome is certainly on them. If something goes wrong in psychotherapy, I would also lean toward placing responsibility on the psychotherapist.

      I’m just thinking aloud, however, and I welcome your thoughts.

      It’s still an incredibly interesting question and I believe a blog post and a reply do not do it enough justice.

      Reply

      • shay
        Sep 22, 2017 @ 21:02:40

        Hey Luke!

        I really appreciate you answering my question. I believe the page you are looking at is page 66. Wright talks about how during the early phase of treatment, the clinician is culpable for structuring and educating. As CBT proceeds, the patient takes more and more responsibility. So I agree with your analysis, that in the beginning of therapy that the bulk of the responsibility (60/40) may lie with the therapist, while towards the end of the therapy there may be a role reversal in which the client gains the upperhand. I’m not quite certain where the 50/50 would lie; perhaps in the middle of the process. Possibly with a higher functioning client, the roles may be 60/40 throughout, with the client mainly taking authority over the relationship. I think we could probably agree that both client and therapist should share near equal responsibility regardless.

        Reply

  10. Luke Dery
    Sep 20, 2017 @ 23:43:36

    (1)
    Given that the establishment of a solid therapeutic relationship is statistically the most important part of effective therapy, it is also essential to effective CBT. Although it is not considered the principal mechanism of change, creating an alliance with your client is crucial to the work done in CBT. General qualities that CBT shares with other therapeutic orientations include genuineness, warmth, positive regard, and accurate empathy. These qualities are important because they create an environment where the client feels safe, secure, and is willing to share about their problems. Accurate empathy, in particular, is essential to CBT in that therapists have to try to put themselves in their clients’ shoes in order to understand their thought process and the contributing factors to possible maladaptive thought. If we can’t see things from the client’s perspective, we cannot hope to help them improve their situation. Accurate empathy in CBT differs from other orientations in that it must be converted into action and the search for solutions. Empathy in CBT is often shown in the therapist’s effort to help the client solve their problems. For example, if your friend’s dog ran away, normal empathy would involve displaying concern for their situation and their emotions. CBT empathy would be assisting your friend in finding the run-away dog. It is important to show genuine interest in not just the client’s concerns, but also genuine interest in finding solutions or helping them in general.
    CBT is also set apart from other orientations by the concept of collaborative empiricism. This term highlights the collaborative nature of CBT work in which the therapist and client share responsibility for establishing goals and objectives, giving and receiving feedback, and engaging in the practice of CBT skills. This is essential to the therapeutic relationship because it gives the client a lot of autonomy in the outcome of their work and fosters a relationship where thoughts and behaviors can be analyzed in a way that doesn’t offend or degrade the client’s emotions or cognitions. People often avoid therapists due to the fear that they will “pick their brain” or “analyze” them. CBT fosters a relationship where clients are stimulated to pick their own brains and analyze themselves with the assistance of the therapist. In this way, CBT therapists become a “teacher of skills” to their clients. While the CBT therapist may have skills and expertise that the client does not, they are eager to share those skills so that their clients can become experts as well.
    I thought the emphasis on using humor in CBT was a refreshing additive to therapy. Of course, humor is a delicate matter, but therapy can often be dark and daunting, and adding appropriate humor seems to add humanity to what could be a sterile experience. After all, we are humors and laughter is a big part of our lives. Wright points out that humor can be used to humanize treatment, break out of rigid or extreme ways of thinking, and strengthening the clients own use of humor as a coping mechanism. Since CBT involving discovering alternate ways of thinking, I believe humor provides a unique perspective in terms of dealing with life’s stressors.

    (2)
    Session structure is important for CBT work for many reasons, but the main point of emphasis is that people coming to therapy often live in confusion, stress, or present with symptoms that make their lives very chaotic and often enjoy and need structure. We are creatures of habit, and CBT involves creating healthy behavioral habits. Session structure not only improves efficiency of learning skills, but provides a model for structure in the lives of our clients. Session structure is also important in setting the standard for the goal-based nature of CBT. In therapy that is unstructured, it seems easier to fall into a state of complacency and tread water. CBT sets out a structured plan for sessions that, at the very least, encourages progress and forward movement.
    Session structure also provides continuity between sessions. Each session involves reviewing homework from the previous session so old material is not forgotten or disregarded. This allows for a scaffolding process in which knowledge and progress is founded, reinforced, and built upon. In our busy lives, it can be easy to forget what was discussed in last week’s therapy session. CBT’s structure allows for a greater level of focus. Session structure also provides opportunity to assess and observe progress. If individuals can’t see the progress they are making, they will most likely become discouraged with therapy. The CBT structure provides time to address progress via homework and feedback, and give clients a sense of how far along they are in developing skills. Finally, having some sort of structure makes it less likely for therapy sessions to turn into progress “stalemates” in which both sides come to standstill. As a beginning therapist, structure provides some comfort to me in that I have somewhat of a guide to follow. I’ve had past experiences with basic “talk therapy” in which we reach a “Okay, now what?” impasse. The structure and progress-focused nature of CBT seems to always keep the ball rolling and fill therapy sessions with material that contributes to reaching the necessary goals.

    Reply

    • Luke Gustavson
      Sep 21, 2017 @ 13:09:34

      Hello,

      You mentioned that the CBT relationship is relatively different from that of other orientations despite there being common ground (mostly due to “common factors”). One of the comments that particularly struck me was your idea that empathy in CBT is functionally different from empathy elsewhere. Accurate empathy in the CBT fashion does appear to be goal-directed and action-oriented much like anything else in CBT.

      We’re mainly reading from Beck’s perspective, it seems, so I’m wondering if you think that accurate empathy from Beck’s orientation could be considered different from Ellis’ understanding of empathy. What do you (or anyone else) think? For my part, I think REBT is likely to promote empathy in a more “tough love” kind of approach, like “Losing your dog is a terrible thing, but what good is laying in bed crying about it going to accomplish? Is it so aaaaawful?”

      Further, you mentioned “appropriate humor.” What might you consider appropriate? I am assuming a “context matters” response, of course, but I’m still curious. I have a dark sense of humor and particularly enjoy gallows humor. Can you imagine an instance where this may be appropriate and not horrific?

      Reply

      • Luke Dery
        Sep 22, 2017 @ 20:46:49

        Hey Luke,

        Appropriate humor is definitely a tender subject, and I’m not sure there’s a clear answer to what makes humor in therapy appropriate other than “you know it when you see it.” First of all, I think it depends on your client’s sense of humor. White points out three elements of humor that I really liked. First, it has to be spontaneous and genuine. I can see forced humor turning easily offensive. Second, it has to be constructive. Finally, it has to be focused on external problems and not on internal characteristics of the client. As clients in CBT start to see their thoughts as passing and not inherently part of them, it really opens to door to use humor. In my brief experience, I’ve had clients laugh about some of their thoughts and say “Wow that’s pretty silly if you say it out lough.” I think that looking at thoughts from an outside perspective allowing clients to distance themselves from their thoughts makes humor safer and more genuine.

        Reply

      • shay
        Sep 22, 2017 @ 21:19:20

        Hey both luke’s! I think humor is something that can be used, but should be used sparingly. I remember learning that in DBT, a similar therapy to CBT, uses sarcasm and humor often with clients. Witnessing this style, I remember feeling a bit put off by the way clients were approached. Humor could potentially make the environment feel less professional. I think the use of humor should depend on the client. I know for some therapists, humor may be a way to connect with clients and establish rapport. Other clients may feel uncomfortable depending on their personality and their expectations of what the therapeutic relationship should look like. I think it depends on what type of relationship you establish with your client. I also think its depends on appropriateness and context. If a client just finished talking about a death or divorce, it may not be entirely appropriate to make light of the situation. A therapist needs to be smart about when humor is going to be accepted by their client, as well as effective. I know Dr. V mentioned that he has used humor, and it works for him.

        Reply

      • Matthew Collin
        Sep 23, 2017 @ 08:18:12

        Hey all,
        I am on the side of humor being a really good thing, but only after rapport and a relationship is established. I mean, depending on the client, like Shay mentioned, it may be appropriate ahead of time, but you can never be too sure. What if your client doesn’t have a sense of humor, doesn’t get the joke, or is blindsided by – as they may see it – a rude and invalidating comment? I feel as humor is something that should be thoroughly thought about before using. For instance, what is the therapeutic significance of me poking fun at this thought, emotion, or situation? This is how I think it should be used instead of being a stand-up comic/ therapist – although, that would be a pretty cool job title.

        Reply

  11. Stephanie Welch
    Sep 21, 2017 @ 06:59:37

    1) My understanding of the therapeutic relationship in CBT is the therapeutic relationship is a collaboration between the therapist and the client. The therapist relationship is often referred to as the therapeutic alliance because it involves the participation of the therapist and the client. Wright et al refer to the therapeutic relationship as a collaboration based on empiricism and interventions intended to promote changes in behavior. The therapist and client work together to form ideas of how the client’s thoughts influence his or her behavior and how to change the problematic thinking. The therapist utilizes methods in therapy that have proven by science to work with clients.
    Beck states that the therapeutic relationship is based upon collaborative empiricism. The therapist and client both work on the client’s problems and examine the thoughts that lead to the problem behavior. Beck points out that collaborative empiricism involves the active participation of the therapist. Instead of just sitting back and listening to the client, the client is engaging the client to think about solutions to his or her problem. Also, the client is not just listening to the therapist but must create ideas for how to approach his or her problem and attempt to implement those ideas. Wright et al adds that collaborative empiricism involves the therapist and client setting goals, agendas, and feedback. Before trying to implement the skills of CBT, the therapist and client must decide on what problems to focus on, how to focus on the problems, and how the problems and therapy are perceived.
    Wright et al points out that a good strong therapeutic relationship creates positive treatment results. The client is going to want to participate in therapy and change his or her behavior if he or she thinks that the therapist has his or her best interest in mind. If the client believes that the therapist understands his or her problems, he or she will also believe that the therapist knows how to work with the client to solve his or her problems. Also, a client in a strong therapeutic alliance with the therapist is more likely to use the skills learned in therapy to apply to his or her life. Judy Beck states that trust, hope, rapport, and focusing on the client’s strengths all contribute to a good therapeutic relationship. By instilling trust and hope into the therapeutic relationship, the therapist is demonstrating to the client that he or she can overcome his or her problems. Rapport and focusing on the client’s strengths also helps the client to focus on what she or he is capable of accomplishing rather than how the problem is affecting her or his life negatively.
    2)It is important to have session structure for effective CBT for many reasons. One reason is that the client may discuss more than one problem. If the therapist can not determine which problem is having the most impact on the client, then the client will never get to solving the problem. Another reason is that the client may have a lot to say about his or her problem. This could lead to the therapist and client never discussing the important features of the problem or how to solve the problem.
    The structure of the session also allows for the therapist to pace the session. CBT is short term with a limited amount of sessions. Sometimes insurance providers cut the limit of the session down even further. In order to be effective in treating the client, the therapist must organize the sessions in a way that addresses everything necessary for treatment. The expectation to the basic structure of the session would be a client in crisis. But even a client in crisis would require a certain approach to the problem that the client is facing. The therapist must be prepared to evaluate the client and determine the best way to solve the crisis effectively and quickly.
    Wright et al points out that structure helps with recovery by providing organization. The agenda of each session allows for the client and therapist to focus on one problem and to pick the most important problem. Wright et al also points out that structure allows for the development of CBT skills. Instead of just focusing on the problem, the therapist and client are also focusing on the potential solution to the problem. The therapist is able to determine what skills the client needs in order to solve his or her problem.
    Judy Beck points out that structure is good for the therapeutic relationship because both the therapist and client knows what to expect, what each want to talk about, and how the therapy will progress. Judy Beck suggests reviewing the intake session and providing psychoeducation for the first CBT session. Judy Beck also suggests allowing for changes to the goals for future sessions in case there are changes in the client’s problems.
    Each part of the session plays a vital role in the client’s treatment. Judy Beck provides an example of the CBT session with reviewing the previous session, checking the client’s mood, setting an agenda for the session, discussing the client’s problem, summarizing the session, and assigning homework. The therapist also gives and receives feedback throughout the therapy session. Feedback allows for the therapist to know whether or not he or she is understanding the client’s problems. Feedback also provides direction by determining whether or not the therapy is effective. Homework provides the framework for the client to utilize the skills learned in the sessions for real world application.

    Reply

    • Sarah Hine
      Sep 22, 2017 @ 16:32:53

      Stephanie,
      Your statement about the benefit of structure even during a crisis situation struck me as important because part of me assumed session structure is basically ignored during a crisis. However, even when a CBT therapist has to stray away from the standard session structure in order to deal with a crisis situation, the overall technique of structure and organizing steps for problem solving can help during these moments too. Some of the aspects of session structure that could be beneficial include performing assessments, prioritizing, focusing on the problem at hand, and problem solving to help deal with behaviors outside of session. Just because a therapist has to be flexible and deal with a difficult problem does not mean that their knowledge and skills related to sessions will not be of use.

      Reply

    • Noella Teylan-Cashman
      Sep 22, 2017 @ 18:25:00

      Stephanie,

      I liked how you emphasized positive outcomes as a result of a strong therapeutic relationship, and explained how that plays out. I felt like that went to show how many different areas of therapy are influenced by the initial relationship established between client and clinician. From there, you went on to talk about how trust, hope, and rapport are essential in building this relationship. While trust and rapport are often understood as being part of the therapeutic relationship, I feel like hope takes the back seat sometimes. Your comment was a good reminder to go the extra mile with clients, beyond simply trust and rapport building, and take the time instill hope.

      Reply

  12. Lindsey
    Sep 21, 2017 @ 11:35:23

    (1) What is your understanding of the therapeutic relationship in CBT (include collaborative empiricism in your discussion)?
    I really enjoyed this week’s reading assignments. In my opinion, the therapist-client relationship is the most important aspect of therapy. A therapist can have all the CBT skills in the world… but without the ability to convey accurate empathy, positive regard, and genuineness, all the CBT skills essentially offer nothing. Perhaps that is a bold statement but in truth, a client must feel supported and respected as part of the therapeutic relationship. This working alliance is what Beck refers to as collaborative empiricism. Collaborative empiricism respects the patient’s right to autonomy and helps the client feel more in control of the therapeutic process. CBT therapists aim to teach clients how to problem solve and cope with a level of confidence and independence. Accurate empathy helps the therapist gauge the client’s thinking patterns and il/logical reasoning. Socratic questioning provides the therapist and client with new insights that might highlight priorities to focus on within the context of therapy. If the therapist pinpoints maladaptive thinking habits, collaborative empiricism allows the therapist and client to work towards sharing responsibilities for goal setting, constructive feedback, and experiential learning with CBT techniques such as homework and relaxation training. Wright compares CBT therapists to that of a teacher or coach. Though therapists act as experts in CBT training, clients are the only experts of him or herself. CBT therapists encourage collaborative empiricism by engaging the client in a stimulating learning environment and empowering the client through psychoeducation. Overall, collaborative relationships are optimal between therapists and clients so they can define problems and identify solutions together.

    (2) Why is it important to have session structure for effective CBT?
    Just as a teacher creates lesson plans for a class, a CBT therapist formulates goals and sets agendas for therapy. Structured sessions set expectations, reduce anxieties for the client, and optimize learning opportunities during the therapeutic process. It is easy for negative automatic thoughts to take over thinking and behavior patterns, especially during the beginning stages of therapy; therefore, a CBT therapist must focus on keeping sessions on track. Structuring sessions through psychoeducation interventions improve the efficiency of therapy, the learning process, hope, and coping skills of the client. Less structure is required during the later stages of therapy because clients learn to take more responsibility for managing their own thoughts and behaviors. Collaborative empiricism encourages therapists and clients to work together towards goal setting and attainment– this includes homework assignments to bridge the gap between sessions. Devising a reminder system to complete homework is one example of session structure that takes place in therapy; this helps the client progress within their own environment outside of therapy. Though structure is important to keep therapy on target, it is equally of value for a therapist to balance structure with expressiveness. The therapist must meet the client where they are and be careful not to push the client to progress when they are not ready. Feedback is a crucial component within the CBT model. Structuring sessions to include time for feedback helps the client learn how to problem solve in a ‘real life’ setting – (i.e. by talking through the area(s) of concern instead of reverting to old thinking/behavioral patterns that have proven to be unsuccessful in times past). I also agree with Beck’s note to set accurate estimations of the duration of homework-specific tasks… this type of structure helps the client maintain perspective and be more realistic with the goals of therapy.

    Reply

    • Sarah Hine
      Sep 22, 2017 @ 16:42:20

      Lindsey,
      I agree that the therapeutic relationship is an essential component to CBT. With a solid understanding and sense of trust between the therapist and client, a client will be more likely to listen to work collaboratively with the therapist, share during sessions, and will be more open to feedback and problem solving. Similarly, I think the effect of a positive relationship on a therapist is also relevant, because the therapist will know how to interact with and respond to the client. Like you mentioned in your comment about flexibility in session structure, it is important for a therapist to know strengths and limitations of a client in order to best organize therapy and structure it according to the client’s needs. The therapeutic alliance is the key to knowing how to alter session structure in a way that is productive and challenging but not too aggressive.

      Reply

  13. Alana Kearney
    Sep 21, 2017 @ 12:17:54

    1.The first thought when someone considers a therapeutic relationship in CBT will most often be a collaborative and cooperative relationship. Like other common therapies, CBT requires therapists to display empathy, warmth, and genuineness in order to create a trusting and safe environment for the clients. However, CBT differs from most therapies because the therapist no longer has complete power in the relationship. CBT therapists focus on creating an equal relationship with their clients so that the client understands that he/she is in charge of driving the therapy depending on what he/she wants and feels able to accomplish. The therapists want to discourage the client from becoming dependent on the therapy sessions and on only the advice of the therapist. CBT is meant to be a short-term therapy and in order to achieve your goals in a short amount of time, the client and therapist must put in the effort together and prepare for the eventual termination of therapy.
    Thus, both Beck and Wright explain that CBT focuses on a collaborative empiricism in which the client and therapist collaborate with each other to share thoughts and ideas, set goals and plans of action, and both give and receive feedback. In this way, the client is made to feel like he/she is in control of his/her own therapy and, therefore, own life. The client can determine what is truly best for his/her health and well-being and decide how confident he/she is in implementing any strategies discussed in sessions into his/her life. If the client is not comfortable with a proposed treatment plan, then the therapist must be flexible to propose new options for the client. I appreciated the way Wright compared CBT therapist to a teacher-coach figure. The therapist has the background in psychology to provide the skills to teach the client and has the benefit of being an outside perspective to encourage the client when he/she succeeds or points out when a certain strategy is not working for the client. However, in the end, the client can perform in whatever he/she feels best for himself/herself. This is why Wright also explains that the therapist is the most important in the first few sessions where the client is learning coping strategies and other techniques in which the CBT professional should be trained. Then the client starts becoming more active in later sessions as he/she takes control of his/her life and treatment.
    Like many others have mentioned, I enjoyed the insert about using humor in CBT. I found this extremely important after reading the passage. Often people will be nervous to go to the first therapy session, nervous to go back if they forgot to do their homework, nervous to try new skills, nervous to admit failures and weaknesses to their therapist. Humor is an outlet that should be used to put the therapist on the same human level as the client. It loosens up the client and decreases feelings of stress and anxiety that may prevent the client from feeling able to succeed in therapy. The client should not have to be scared or nervous about seeking help, which is why CBT therapists should be encouraging, empathetic, warm, genuine, flexible, and relatable.
    2. Although a CBT therapist must be flexible in therapy to better adapt to the client and his/her needs, CBT is a structured therapy that requires many important steps. Since the concept is to develop helpful strategies for long-term issues in a short period of time, it is important for CBT therapists to follow a certain structure.
    Structure provides a plan of action for both in and out of session. The steps that make up the CBT structure are all important in order to achieve goals and better the client’s life. Clients seek therapy when they feel desperate for answers and help for the problems they are suffering. Not only is it important to be warm and welcoming, it is also important to show them in the first session that there are steps they can take in order to better their own lives and hopefully solve some of their personal problems. Goal setting is an important step so that the client sees that it is possible to change and after steps are completed it is important for the client to provide feedback about how well the techniques worked for him/her. Similarly, it is important for the therapist to check in and provide feedback about how he/she thinks the therapy is going. After evaluating the progression of the client’s work, the therapist and client come up with homework assignments that brings therapeutic techniques into the client’s own actual life. Without goals, the therapy has no focus or point. Without homework, therapeutic techniques are useless to teach or to learn. Without feedback, there is no understanding of how the client is fairing with the therapy sessions. Without symptom checks, the therapist has no idea if the client’s problems are improving and thus if he/she is truly benefiting from therapy.
    Therefore, structure is clearly an important part of CBT therapies. It is important to show the client that he/she is making strides in therapy so that he/she is motivated to continue and maintain these good habits even after therapy has to end. Structure can also be important when the client faces inevitable road bumps in every day life and feels unable to overcome obstacles. Feedback from previous sessions can remind the client that he/she is capable of much more than he/she may believe by using the skills taught thought psychoeducation during therapy sessions.

    Reply

    • Stephanie Welch
      Sep 22, 2017 @ 23:28:22

      Alana,
      I am glad that you mentioned Wright’s comparison of the CBT therapist to a teacher-coach. When I read that analogy, I felt like it was an appropriate way to think of the therapeutic relationship. I feel like you defined it very well with the client learning the coping strategies. I also think that your emphasis on the client gaining control of his or her life was a very important point to make. Sometimes we just focus on the smaller details of the problems, and do not realize that the clients are gaining skills to change their lives.

      Reply

    • Lindsey
      Sep 24, 2017 @ 08:01:44

      Hi Alana,
      I enjoyed reading your assessment of the therapeutic alliance because it really drives home the value of CBT. Without an agenda, goal setting, feedback, or homework – what gives? This week’s readings really made me take a step back to assess other theoretical orientations. In PSY 600, we spent most of our time talking about other orientations so now… for us to really dive into CBT, it makes you wonder what the heck other (non-CBT) therapists are doing….??? I don’t say that to sound rude but in all seriousness, do they not have any form of a treatment plan? Do they not set goals with the clients? Do they enter the field without any intention of offering time-limited treatment? Personally speaking, I’ve sought therapy in the past and none of those options were offered — with that said, I can’t help but to wonder about what the therapist thinks they might be achieving when they opt out of using an evidence-based practice like CBT…

      The therapeutic alliance is extremely important because without it, the clinician’s CBT skills mean nothing. Likewise, without the clinician’s application of CBT skills, how much help/progress can a client actually receive/make?

      Reply

  14. Chiara Nottie
    Sep 21, 2017 @ 12:21:12

    Therapeutic Relationship:
    The therapeutic alliance, collaborative empiricism, or therapeutic relationship, however you refer to it by, it is essentially the established rapport between client and clinician that helps therapy progress. Therapeutic relationship is not a bond like friendship, but rather a trusting dynamic more like team membership. Considering the therapeutic relationship as a relationship among team members is why the phrase collaborative empiricism is utilized. Collaborative empiricism suggests an equal working between two entities, as well as a level of expertise. The therapeutic relationship not only helps clients feel comfortable enough to share information with their clinician, but it allows them to trust treatment exercises that a clinician suggests (Wright et al., 2006). Thus, in return the therapeutic relationship allows the clinician to access important information from their clients, try therapeutic exercises with them, and to gauge a client’s limits, or comfort towards certain things, which can help with planning future sessions. Research has even shown that successful therapy outcome depends on the therapeutic relationship, and without an established alliance, clients may feel misunderstood, and unmotivated to return to future therapy sessions, or dedicate full effort to homework assignments, diminishing the quality of their treatment (Wright et al., 2006). The importance of the therapeutic alliance influences how immediately clinicians attempt to establish during therapy. Expectedly the therapeutic relationship takes time to develop and can’t be rushed, but usually clinicians even from the first intake session will work hard to begin to develop it. Influence from Carl Rogers seeps into all branches of therapy when it comes to establishing a therapeutic rapport. Carl Rogers believed it takes empathy, warmth, and genuineness (among other things) to establish trust and respect between clients and clinicians. The difficulty with these factors are displaying the right amount, it can backfire if a clinician comes across too sympathetic, or not genuine enough towards their clients (Wright et al., 2006). You can think of this as the goldilocks effect.

    Session Structure:
    Along with the therapeutic relationship, a structure to therapy sessions is important as well (in CBT). CBT likes structure because it helps guide a treatment strategy. CBT is a very active therapy, so having a set guide of how to play out progress only makes sense. Supposedly, during an intake session a clinician will have a conceptualization of the case and will want to form a treatment plan. CBT believes a treatment plan is helpful to therapeutic success so clinicians and clients aren’t spending every session wandering through thoughts and never completely addressing main issues. The therapeutic relationship comes into play when structuring a session. A CBT clinician will want to accomplish a lot of things during a session, such as, setting an agenda, doing a mood check, obtaining an update, discussing the diagnosis, set goals, identify problems, educate the client, summarize the session, assign homework, and receive feedback from the client (Beck, 2011). In CBT, there is an overall structure to obtain treatment progress, but individual sessions come with their own structure as well. At the start of each session the clinician with the feedback from the client will “set the agenda” for the session, meaning the clinician with input from the client will decide how the session will go, and what will be addressed. CBT believes in the influential relationship between thoughts, feelings, and behaviors, so doing a “mood check” helps the clinician and client see how the client is feeling, and how those feelings may be effecting their thoughts and behaviors (or vice versa). Similar to mood checks, the clinician should ask their clients to update them on how they are currently doing in life, and what has transpired in their (the clients’) life since the last session. This update helps the clinician to know if treatment elements such as particular homework assignments have been effective for the client, if anything significant has changed in how the client thinks, feels, or acts, and whether there is certain psychoeducation the client might need. The therapeutic relationship should make the client feel like they can trust the clinician with that information. A great deal of time will then be dedicated towards exploring the strengths, weaknesses, and knowledge the client has, through this, identifying key problems that arise for the client will help the clinician understand what treatment plans will need to be utilized. Once problems are identified clinicians along with clients can set goals that address these problems. Setting goals is an obvious part of therapy that illustrates the collaborative nature between the clinicians and client, because only the clients knows what they would like to improve, and a clinician may be able to help prioritize these goals. After obtaining updated information, identifying problems, and setting goals, educating the client about CBT models, and discussing the client’s diagnosis can occur. Understanding the concepts that CBT believes in and how they apply to a diagnosis is always necessary for therapeutic treatment (Beck, 2011). Towards the end of the session the clinician will summarize what transpired, and assign homework for the client to do before the next session. Homework is one of CBT’s signature treatment techniques. Homework assignments allow clients to take their progress into their own hands. Homework assignments can continuously educate clients about CBT, and their diagnosis. The most important thing homework assignments do, is to keep treatment going for a client between sessions. With the use of homework assignments, sessional updates can be done, and mood checks may change depending on how successful treatment is going. The final part to a therapy session is feedback. Although feedback can occur during other points in therapy to address possible problems, or suggest improvements, feedback before a session ends is a good idea. Feedback again illustrates the collaborative work between clinicians and clients, and it helps strengthen the therapeutic relationship. All of these different structures to a CBT therapy session can play out in different orders depending on the case, and if it may seem appropriate to do a mood check again, before discussing a diagnosis, for example (Beck, 2011). The structure to CBT like the theoretical models, has an intelligent connection, and purpose.

    Reply

    • Alana Kearney
      Sep 21, 2017 @ 15:18:42

      Hi Chiara, I appreciated your comment that a therapeutic relationship is similar to that of two team members. In the book, they compared therapists to coaches, but your analogy to equal team members made more sense to me. After all, you can learn just as much from other players on a team than you can from a coach. Often time coaches were once players, which is why they know as much as they do about the sport. The analogy to a coach made it seem like a more dominant or powerful position, but I think the therapeutic relationship should also be more of a team membership.

      Reply

    • Noella Teylan-Cashman
      Sep 22, 2017 @ 18:10:29

      Chiara,

      I thought you did a great job of outlining the structure of therapy, as well as explaining the relevance of structure. You also touched upon the importance of the therapeutic relationship in the context of session structure, which I thought was a vital point to address. Without a strong therapeutic relationship, the client will not feel comfortable participating in structured activities such as mood checks, updates, and goal setting. The therapeutic relationship serves as the foundational structure for the rest of the process. Like any other foundation, if it is not strong, you cannot build upon it.

      Reply

    • Luke Dery
      Sep 22, 2017 @ 20:56:35

      Hi Chiara,

      I liked your point about a healthy therapeutic relationship allowing clients to trust homework assignments. Since homework has been shown by research to be an effective part of therapy, it’s important that we find ways to motivate our clients to do it in their busy lives. If you don’t like your therapist, it makes sense to not trust their methods. But if the client sees their therapist as an expert, that’s going to make them put more stock into what the therapist assigns/suggests. Also, the collaborative practice that goes into creating homework assignments appears to be key, as clients will be more likely to engage in assignments they like or helped develop.

      Reply

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Adam M. Volungis, PhD, LMHC

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