Topic 3: The Practice of CBT – Therapeutic Relationship & Session Structure {by 2/8}

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 2/8.  Have your two replies posted no later than 2/10.  *Please remember to click the “reply” button when posting a reply.  This makes it easier for the reader to follow the blog postings.

32 Comments (+add yours?)

  1. Cassie McGrath
    Feb 05, 2018 @ 18:37:04

    1 What is your understanding of the therapeutic relationship in CBT (include collaborative empiricism in your discussion)?

    It is my understanding that the therapeutic relationship between a client and the therapist is crucial to the progress that occurs in any form of therapy. The therapeutic relationship is especially important in CBT because the process that occurs within CBT is developed and successful through collaboration between the client and the clinician. In CBT, the client and the clinician work together to develop goals for where the client would like to go. In relation, the clinician and the client work together to make progress towards these goals. The relationship between the client and the clinician is important because as the client moves through progress it is important that the clinician has some understanding of the client’s thoughts and feelings. If there is not a positive therapeutic relationship between the client and the clinician it is possible that progress will not be as effective. If there is a lack of a positive therapeutic relationship there may be less collaboration that occurs as well. The collaboration is extremely important because the clinician and client are going to work together to come up with things that the client will work on and if the client does not feel he or she has a say in these tasks or homework assignments or if he or she does not feel like the suggestions are feasible for the client then the client is less likely to successfully complete these and to successfully complete their sessions with the clinician.

    2 Why is it important to have session structure for effective CBT?

    Session structure is another important aspect to CBT as well as some other forms of therapy. CBT is goal driven meaning that the client has a set goal or goals for their treatment. CBT is not a therapy that is supposed to last forever, there is a schedule to the process. When a client arrives to a CBT session the clinician should have a goal for the session. These sessions are not meant to be talk therapy sessions, each session is meant to work towards the goal of the client. Ensuring that there is session structure ensures that there is consistent movement towards the client’s goals. If there is no structure there may be less progress. In general, having structure is also important to ensure that the client is aware of the process of therapy. It is important that there is structure so that the client does not come into a session having little to no concept of what they are working towards. The client should feel that they know the direction they are going and that they are consistently working towards their goal.

    Reply

    • Aleksa Golloshi
      Feb 10, 2018 @ 08:42:15

      Hi Cassie,

      I like how you directly state that CBT is not suppose to last forever, which I think is a common error in most therapies. I also like that you describe how the clinician should have a goal for each session to ensure that there is constant movement, which will help the client work towards their maladaptive behavior. Having structure to each session makes the client aware of what is actually being done, which I believe will boost their confidence in the therapeutic process overall. I also like when you state that therapy should not be “talk sessions” because the client does not really gain much from this. They might feel better about a certain conflict that they’re talking to you about but once they leave the office that conflict will probably upset them again. They did not learn any application skills on how to alter their thinking on the conflict and therefore simply just talking about the conflict solved nothing.

      Reply

    • Teresa DiTommaso
      Feb 11, 2018 @ 09:56:33

      Hi Cassie,

      One of the most important aspects I think you touched on is that CBT is goal-oriented. I really think you hit the nail on the head when you said that without structure, then progress towards said goals is going to be difficult. I really liked how you mentioned the part relating to psychoeducation as well. Having the client be aware of the process is such an important point and one I did not think of as it relates to structure. So I really appreciate you sharing that perspective!

      Reply

  2. Tori Bryant
    Feb 07, 2018 @ 14:45:01

    1) The therapeutic relationship in CBT requires a highly active alliance between client and therapist. By “active” I mean that the therapist is working to meet the client’s needs through even the most challenging of changes and dynamics. CBT can come across as cold and data driven if someone is just looking at the surface of the therapeutic perspective; however, when diving deeper it is clear that a therapist who practices CBT needs to discover his or her client’s maladaptive cognitions by using genuineness, warmth, and empathy. Empathy does need to be accurate to prevent buying into a client’s distortions, too much warmth can be seen as approving of these distortions, and there needs to be a sense of genuine and realistic optimism to encourage the client to proceed through therapy with hope, a sense that they are understood, and that someone is going to hold the client accountable because they care. Clients should understand that they are expected to do work in therapy and outside of sessions through homework.
    Collaborative empiricism speaks to the CBT therapeutic relationship because it acknowledges that both therapist and client have to be working actively and intentionally to make change. Both parties are responsible for working on receiving and giving feedback, creating agendas and goals, and applying CBT methods to their actions in their day-to-day activities. All of these collaborative tasks are set in place so that the client and therapist can work together to empirically discover and change maladaptive cognitions and in turn, correct maladaptive behavior.

    2) It is important to have session structure for effective CBT because it would be fairly easy to find yourself as a therapist off track when helping a client through his or her problems. When there is an agenda set, goals to set and track, and symptom/mood checks a therapist can move in a positive direction for change instead of letting unproductive tangents happen throughout the session that distract from the core issues at play. So much happens to clients in their day-to-day lives that they may want to talk about with their therapist, but CBT is not meant to be long-term therapy; therefore, it is important to stay focused on the achievable goals that have been put in place to instill change in clients.
    It is much easier for the therapists to direct their conversations with clients back to productive topics if both client and therapist have set an agenda they want to work on together. Often times if the client states he or she wants to work on something and make it a priority, he or she will not mind being redirected to what was agreed to be worked upon. With how dynamic human beings are and everyday occurrences that happen, we could all be on therapy for a very long time if we did not get down to the root of our behaviors and cognitions and that is what CBT strives to do efficiently through providing the client and therapist with a structure to work off of.

    Reply

    • Sarah Mombourquette
      Feb 08, 2018 @ 15:43:35

      Hi Tori, I like that you pointed out the misconceptions about CBT as a therapeutic orientation. The evidence-based treatments used in CBT would not be as effective if one were to use a “cold approach.” As you said, CBT is driven by a strong emphasis on genuineness, warmth and empathy. I also liked your examples of what could happen if these approaches are overemphasized. Ultimately, it could be detrimental to both the therapeutic relationship and the therapeutic process if a clinician did not find the correct balance. In your discussion about session structure, I think your most important point was how structure aids in preventing CBT from becoming long-term therapy. Structuring each session allows the clinician and client to stay on track and focused, creating a more efficient therapeutic process. Like you said, it would be very easy to stray from the root of behaviors and cognitions without structure to guide us in the right direction.

      Reply

    • Matthew L
      Feb 10, 2018 @ 18:59:11

      Hi Tori,

      I think you made a lot of great points in your post. I really like how you pointed out that CBT can come across as cold and data driven. Because we spend so much time learning and understanding CBT it is easy to forget how it may appear to others. Given that one of CBT’s strongest and often initial selling points is its research proven effectiveness and scientific based understanding it certainly can give the impression that it is a cold form of therapy. Obviously that impression is the opposite of true and I also feel you explained the importance of emotional qualities well in the context of CBT. CBT requires the proper balance of emotional qualities so that therapy feels warm and inviting but also not overbearing.

      Reply

  3. Sarah Mombourquette
    Feb 07, 2018 @ 14:53:12

    1) In any clinical setting, the therapeutic relationship involves genuineness, warmth, positive regard, and accurate empathy. The significance of empathy is that it allows for the clinician to “feel with” the client. What makes the therapeutic relationship different from a regular relationship, however, is that the clinician remains objective so that he or she can discover illogical reasoning and maladaptive behavior patterns. The therapeutic relationship also requires that the clinician regularly evaluate his or her actions within the relationship. For example, a clinician who is different from his or her client should try to do research about the culture of a given population so that he or she can learn more about the experiences of the client. Similarly, the clinician should always try to be aware of countertransference and other clinician-based problems that could interfere with the way the relationship develops. CBT emphasizes the importance of collaborative empiricism. This is the idea that the clinician and the client share responsibility within the therapeutic process. This could include shared responsibility in setting goals and in giving and receiving feedback. The client and clinician will also work together to understand, identify, and target maladaptive thoughts and behaviors. The patterns that are identified are viewed through an empirical lens. This is important because it makes the therapeutic relationship within CBT more individualized. The process focuses on the observations of individual experiences and what could help rather than trusting theories as a “one size fits all.”

    2) CBT often emphasizes the importance of learning for a client. Session structure is a way that CBT looks to promote learning. This is because structuring can help to keep the treatment organized, ensure that sessions are efficient, and maintain a path that is on-target. The ultimate goals of structuring are to “generate hope, boost the learning process, improve the efficiency of therapy, and help the patient build effective coping skills.” It is the clinician’s hope that responsibility for these goals will shift from the clinician to the client as sessions progress. There are many ways to structure a session, all of which can enhance the therapeutic process. Goal setting allows the client to practice setting specific, measurable targets for change. Goals are important in CBT because they allow a client to see consistent improvement towards the goal. Agenda setting is the structure of each individual session. As sessions continue, the client will learn to focus on specific concerns through setting a concrete agenda. Similarly, symptom checks also add a structuring item to the therapy session while simultaneously providing regular estimates of progress. Feedback is encouraged in CBT because it can help to maintain or reinforce session structure, help to improve and build the therapeutic relationship, and correct misunderstandings. Lastly, homework is a way to maintain structure in between sessions that also works to promote CBT skills in managing problems.

    Reply

    • Tori Bryant
      Feb 10, 2018 @ 22:37:20

      Hi Sarah,
      I like how your response to question 2 involves the client becoming their own therapist. In other therapeutic perspectives it can seem like the therapist is simply there to talk to the client or that the therapist may be going as far as to make the client dependent on them. It is crucial that the CBT therapist not want dependence for their client, so as we conduct therapy in our practicum and internship it will be important for us to provide psychoeduation to ensure that the client comprehends the importance of independence.

      Reply

    • Allexys Burbo
      Feb 10, 2018 @ 22:44:47

      Hey Sarah,

      The point you make in differentiating the therapeutic relationship from other relationships is an important distinction to note. Within the context of CBT, while collaborative in nature, it is essential that the role of both client and clinician are explicit – that is, the client is the primary source of change while the clinician’s role is to offer guidance and perpetuate positive change in an objective, evaluative, and collaborative way. With that said, because the clinician acts as the secondary source of change, it is important that the clinician develops an awareness of his/her own potential biases as a means of protecting the integrity of the therapeutic relationship. As you noted, the therapeutic alliance within CBT is one that is individualized and although theory helps direct and focus the approach the most defining feature is that it leaves much to the discretion of the individual experience. In this instance, it is not theory which drives therapy, but rather the collaborative work of both client and clinician through the therapeutic alliance which determines treatment outcomes.

      Reply

  4. Stephanie Mourad
    Feb 07, 2018 @ 19:59:41

    (1) What is your understanding of the therapeutic relationship in CBT (include collaborative empiricism in your discussion)?

    The therapeutic relationship in CBT is one that is collaborative with the client and therapist. Therapy should not be about the therapist telling the clients what to do and giving the clients answers that could solve their problem. It does not work like that. Instead, the therapist should be more of a guide to the client. They should help clients come up with goals to complete, help the client express their emotions, and work together with the client to come up with solutions. Collaborative empiricism is when both the therapist and client are active participants throughout therapy. It is an action orientated therapeutic alliance driven by research that integrates, tests, and modifies client’s thoughts and emotions. Working together with a client is more professional than having the client talk about their problems and then giving the answers to the client. Clients should be expected to put in work during therapy sessions and outside therapy sessions.

    (2) Why is it important to have session structure for effective CBT?

    Effective structuring techniques enhance learning by keeping treatment well organized, efficient, and on target. The overall goals of structuring and educating are to generate hope, boost the learning process, improve the efficiency of therapy, and help the patient build effective coping skills. In the pre-session stage, therapists review client information, and then give a pre-session formal assessment. The Early Session stage is more of a check in and therapists check client mood and emotions. Setting agendas is also important and is a driving force for the direction of therapy. During the middle sessions, its important to review problems, come up with problem solving strategies, and give feedback ands summarize. The late sessions stages focuses on summarizing important themes, assign and review homework for next session, and ask any final questions and give feedback.

    Reply

    • Sarah Mombourquette
      Feb 08, 2018 @ 15:44:51

      Hi Stephanie, I think that you highlighted a really important point in how the therapeutic relationship in CBT differs from other therapeutic relationships: the clinician is not responsible for telling the client what to do. Rather, as you said, the relationship built in CBT is a collaborative one that aims to share responsibility for action between the clinician and the client. I think that this is important because it places a certain degree of control on the client, which prevents the client from complete reliance on the clinician to solve his or her problems. I like that you explained the session structure process with the labels early, middle, and late because it further emphasizes that, from the beginning, CBT is not meant to last forever. Rather, the client is expected to eventually be able to use the skills he or she has learned in CBT in order to manage real-life stressors.

      Reply

    • Cassie McGrath
      Feb 09, 2018 @ 14:08:59

      Hey Stephanie,

      I really like the way in which you talked about the therapeutic relationship and the therapeutic alliance. It is incredibly important to understand that with CBT the progress is best seen through collaboration. You also talked about how there is an integration, testing, and modifying of the clients thoughts. You bring up a good point in this clarifying that it is the therapist’s role to work on this with the client not to control the course of action completely. This connects with how you then talk about session structuring and the how that impacts sessions as well. Together there is a connection between the collaborative relationship between the client and the therapist and the session structure that the therapist sets up. The session structure also gives some control to the client as the sessions progress. All of these things that you discussed are connected.

      Reply

    • Louis D’Angelo
      Feb 10, 2018 @ 20:13:34

      Hey Stephanie,

      I loved how you described the therapist as a guide to home the client make goals and work on emotional regulation. A term we discussed in class, as well as in development, is “scaffolding”. More known as the stuff workers sit on while they eat their lunch after working on construction, scaffolding in the therapeutic Seneca is simply providing support and guidance to actively allow the client to build up there goals and progress. Once proper support has been given, the scaffolding can then be removed and allow the client, or building, to stand independently.

      Reply

    • Teresa DiTommaso
      Feb 11, 2018 @ 10:01:23

      Hi Steph,

      Two things that you mentioned that I really appreciated is when you talked about the therapeutic relationship in relation to it being professional and the importance of the client working outside of therapy sessions. It really related to our class on Thursday, regarding homework. The connection you made between the therapeutic relationships and outside work was one I missed. Without this collaborative relationship between the therapist and the client, that aspect of therapy is non-existent. If the client is not an active participant inside the therapy sessions, then he or she will be unable to work outside of therapy sessions, which is one of the core components of CBT.

      Reply

  5. Teresa DiTommaso
    Feb 07, 2018 @ 20:53:58

    1. The emphasis of the therapeutic relationship within the CBT tradition is that it is first and foremost a collaborative process. This is directly in line with the idea of collaborative empiricism, the idea that both the therapist and the client are responsible within the treatment context and that the process is never one-sided. Foundational ways that the therapist can make sure that the therapeutic process is collaborative is through feedback and summaries. This allows for a clear path of communication between the therapist and the client in making sure all is well within the therapeutic alliance and the patient is comfortable and feeling understood. Without feedback, there is no way to know if the therapist needs to change his or her style or treatment. Additionally, summaries allow for the therapist to confirm their understanding of what the client is feeling or trying portraying. In addition to the therapeutic alliance being collaborative, the therapeutic relationship must be based in empathy, compassion, and trust in order to establish a good rapport. Without a good relationship, then the skills needed to help the clients are ineffective. Additionally, evidence supports that positive therapeutic relationships are correlated with positive treatment outcomes (Beck, 17).
    2. Especially at the beginning of one’s career, it is important to have session structure. Having a session structure not only helps you, as a therapist, stay organized and effective, but it helps the client as well. With structure, a client continually knows what to expect from the session. The structure provides a basis for continual and reliable assessment, which is very important in evaluating progress on mood and treatment progress. Particularly important to the structure is identifying problems and setting goals during the first session. It is through this structure that very clear tasks can be established, which lend themselves to case conceptualization and treatment planning. I also think structuring sets the stage for better communication and understanding between the therapist and the client. When therapists and clients are able to set and prioritize an agenda, perform updates, review homework, work on specific problems, and provide feedback and summaries it allows for a clearer collaborative process. Without structure, the client may focus on one particular issue; perhaps one that may not even be related to the presenting problem and the therapist would be very ineffective and inefficient. Without structure, a CBT therapist would be unable to elicit particular automatic thoughts from the client and they would be unable to work through treatment interventions together. I think it is also important to mention that although structure is key to an effective treatment plan, a therapist needs to be able to recognize when the client needs to spend more time on one issue, especially if the client is extremely distressed.

    Reply

    • Lexie Ford-Clottey
      Feb 08, 2018 @ 10:27:26

      Hi Teresa,
      In your response to why session structure is necessary within the framework of CBT, I appreciate you mentioning the importance of this element for those just beginning to practice as a CBT therapist. It never occurred to me how difficult it would be to interact with clients or conduct therapy without a certain amount of structure or organization. Jumping into therapy without direction or a set agenda is quite risky, in which the therapist can come off as incompetent or appear uncertain in how to deal with the amount of client problems. This comment really put into perspective how essential session structure is to the process of therapy, and how a beginner therapist can utilize this structure to stay on task. I also like how you highlight session structure as an effective way to build communication and understanding between the client and therapist. In my opinion, if the therapist and client are not on the same page through the course of therapy it would become quite difficult to facilitate collaboration and active participation. Since clients are active participants to the change process it is important that communication is prioritized within the therapeutic relationship.

      Reply

    • Matthew L
      Feb 10, 2018 @ 19:21:06

      Hi Teresa,

      I liked the points you made in regards to session structure. In particular I like how you viewed the impact session structure has on the client and the therapeutic relationship. There are many different factors that can impact how a client feels about a therapist and their therapy. Having good session structure provides them with consistency that can be very beneficial for strengthening the therapeutic relationship.

      Reply

    • Allexys Burbo
      Feb 10, 2018 @ 23:29:55

      Hey Teresa,

      The perspective you provide around the value of session structure is especially fundamental to CBT. As the foundation of CBT is dependent on an empirically sound system, the need for structure is imperative. As you emphasized, structure provides a baseline for gathering reliable information, evaluating progress, and identifying/establishing goals. By simply managing the condition of sessions (by creating structure), the clinician is not only able to preserve the momentum of treatment by establishing clear goals and direction, he/she is also demonstrating at another level a feature of the therapeutic relationship – that is, expertness. As you mentioned, the clinician’s ability to model organization and preparedness through the structure of sessions may help perpetuate and reinforce a collaborative environment. In this instance, the client may be more open to experience or inclined to work alongside one who can exhibit such qualities. Furthermore, this work may help strengthen the client’s confidence in the clinician’s role as a professional and skilled addition to the therapeutic alliance.

      Reply

  6. Lexie Ford-Clottey
    Feb 07, 2018 @ 22:44:22

    1. The therapeutic relationship in CBT plays an essential role through the course of therapy and particularly in treatment outcomes, but is not considered the active ingredient for change as displayed in other forms of therapy. To my understanding, a sound therapeutic alliance is characterized by a wide variety of skills (non-specific and specific factors) that help facilitate cognitive and behavioral change in clients and successful treatment outcomes. The non-specific features of the client-therapist relationship often include the Rogerian qualities of empathy, genuineness, and warmth. When a CBT therapist empathizes with a client this means he/she is trying to understand the client by focusing on the validation of emotions rather than thoughts. It is also important that clinicians appear authentic while in session with clients, indicating that reactions and responses should come off as honest and natural. How clinicians conduct themselves during client interactions also matters, in which maintaining appropriate eye contact and speaking in a warm tone of voice is appealing. When done correctly, these facilitative conditions are likely to promote and strengthen a healthy working alliance, but should not be viewed as sufficient to the change process. With this said, CBT places a greater significance on the specific factors involved in the therapeutic relationship, and most notably the concept of collaborative empiricism. Collaborative empiricism can be viewed as a joint effort between the client and therapist in setting goals, giving and receiving feedback, and implementing treatment strategies. This teamwork approach allows for the therapist to be viewed as a teacher in this process rather than a dictator, indicating that clients are active participants to their own change. The primary focus of collaborative empiricism is for the client and therapist to work together to define, understand, and label maladaptive cognitions and thoughts from an empirical viewpoint. More specifically, this collaborative process helps clients answer “What’s the evidence for and against this happening?” or “What are the facts for these claims?” By assessing the utility and validity of maladaptive cognitions, the therapist and client can work towards establishing ways to improve quality of life. With this said, the therapeutic relationship in CBT is quite complex and involves an integration of facilitative conditions (e.g., empathy, warmth, etc) and collaboration in order to determine the effectiveness of therapy for clients.

    2. With CBT being a time limited therapy not meant to last forever, session structure is an important feature because it promotes learning by keeping the course of treatment organized, efficient, and on track. With CBT typically consisting of 16 sessions or fewer, every minute in a session is precious and crucial, in which a therapist wants to maximize the time he/she has to help clients deal with the issues that are most important to them. With CBT being a goal-oriented form of therapy, it is no surprise that the structure of these sessions are focused on prioritizing the problems on the agenda and making progress towards the set goal. Agenda setting is used to structure individual sessions and should always be related to the overall goal of therapy. Items on the agenda are usually specific and measurable, and involve clients tackling pieces of the main problem as part of the change process. Other important elements that add structure to CBT sessions include a mood check, obtaining updates from clients, feedback, and homework. In my opinion, effective structuring techniques provide clients with a clear understanding to the process of therapy, how treatment typically proceeds, and what is to be expected from them. Without structure, it might become very unclear to both the therapist and the client as to what problems need to be prioritized and how the course of treatment should be implemented. It is also possible that a lack of structure can impede the change process and negatively affect the therapeutic relationship. With this said, session structure in CBT influences all aspects of the therapeutic process and plays a major role in therapy outcomes.

    Reply

    • Cassie McGrath
      Feb 09, 2018 @ 14:29:16

      Hey Lexie,

      You mention some really important factors regarding the therapeutic alliance. One important factor that you bring up is that the clinician needs to appear authentic. You discussed how there is not just an importance that the clinician is including the client in the therapeutic process but that it is important for the clinician to conduct themselves in a professional way that best benefits the client. There is more to the relationship then just the collaboration and you bring up good points about the other aspects of the relationship that influence this collaboration. There is a need for a positive relationship in order for collaboration to be affective. When you begin to talk about session structure you relate it well back to the therapeutic relationship and the way in which CBT sessions are not forever. Knowing that these sessions are not meant to last forever makes it even more important for the client has a positive therapeutic relationship with the clinician that way the most positive progress can be made through the sessions.

      Reply

  7. Aleksa Golloshi
    Feb 08, 2018 @ 00:22:19

    1. CBT is a collaborative and action-oriented therapy that places a lot of emphasize on the relationship between the client and the therapist. Each session should display genuineness, warmth, positive regard, and accurate empathy to ensure the therapy is effective. Genuineness refers to communicating verbally and nonverbally in an honest and emotionally connected manner so that the client knows they are being understood. Warmth also refers to understanding the client but in a sincere way so that the client experiences more positive feelings, which encourages them to share more details with the therapist. Warmth relates to positive regard, which means that the less judgment a client feels the more likely they are to share their thoughts and emotions, even if they are disruptive or maladaptive. Accurate empathy is also vital in this therapeutic relationship because it allows the therapist to place himself or herself in the position of the client so that they have a better understanding as to what their client is feeling or thinking. The therapist should focus on validating the emotions of their client rather than their thoughts.

    Collaborative empiricism is another important factor that should be incorporated into CBT sessions. Collaborative empiricism refers to a patient identifying, evaluating, and responding to dysfunctional thoughts and beliefs. The therapist will engage the client in a process of helping them set goals, giving and receiving feedback, and using CBT methods into action in their everyday life. They will then target problematic thoughts and behaviors, which are then empirically tested for validity and utility. Collaborative empiricism is a vital aspect to CBT because it helps the client identify cognitive distortions and unproductive behavioral patterns. Once these are identified the client can focus on altering them in an adaptive way so that they can live a healthier life.

    2. It is important to have sentence structure for effective CBT because it enhances learning by keeping treatment organized, efficient, and on target. Structuring helps the client generate hope, boosts their learning process, and helps them build effective coping skills. A few important aspects to the structure of CBT are goal setting, agenda setting, and symptom checks. Goal setting typically occurs towards the end of the first session, when the client’s main problems and strengths are assessed. By setting goals the client can learn the value of setting specific, measurable targets that will help them change. Agenda setting is utilized to structure individual sessions. Agenda items are specific and measurable and relate to the overall goals of therapy. Symptom checks are also important to incorporate in session structure because they provide a valuable estimate of progress to the therapy sessions. Wright and colleagues emphasize that some elements of session structure are maintained throughout the entire therapeutic process, while more structure occurs during the initial sessions than later sessions. Structure is used during the first sessions because clients are typically more symptomatic and have difficulty concentrating or remembering. They are also more likely to feel hopeless and have not yet learned any CBT skills that would help them cope with their maladaptive emotions and thoughts. As the client partakes in more sessions the less structure is needed because they will have acquired skills in using CBT methods that will help them manage their own therapy in the future.

    Reply

    • Stephanie Mourad
      Feb 09, 2018 @ 23:17:15

      Hi Aleska,
      I agree that genuine, warmth, and empathy are vital in the therapeutic relationship. Without these, the relationship between therapist and client will not be a real one. The therapist must be able to place themselves in the shoes of their client and I like how you said that validating emotions are more important than validating thoughts. Clients should be able to feel a connection with therapists and feel like they understand the emotions they are going through.
      I like that you also said that structure generates hope, boosts learning process, and helps build effective coping skills. Without organization and structure, the therapeutic process could get messy. The therapist should have an agenda and plan with their client and the client must also understand the role they are given in this process. So clients should understand that they are required to complete homework and this should be establishes at the first session.

      Reply

    • Tori Bryant
      Feb 10, 2018 @ 22:40:29

      Hi Aleksa,
      I like how you pointed out in your response to question 1 that CBT and the therapeutic relationship is action-oriented. Both parties come together to pursue specific goals and agendas to make sure the client buys in to what is being worked on and the therapist can also drive the conversation in a positive, constructive way so change can be instilled in cognitions and behaviors.

      Reply

  8. Matthew L
    Feb 08, 2018 @ 07:30:47

    1. What is your understanding of the therapeutic relationship in CBT (include collaborative empiricism in your discussion)?

    When learning the very basics of therapy we are taught about the importance of some fundamental qualities that all good therapists are expected to have. These qualities are empathy, positive regard, genuineness, expertness, trustworthiness, and attractiveness. Each one plays a crucial role in building a therapeutic relationship with a client. While we are taught that each skill is equally important that variability in how those skills are applied within the therapeutic setting cannot only reflect a therapists unique style but also their therapeutic discipline. Different forms of therapy place different levels of emphasis on these qualities and in doing so dictate a certain therapeutic process. Some forms of therapy lower the importance of attractiveness and positive regard and encourage the therapist to be more abrasive. Others further stress empathy and desire the therapist to act more like a mirror for their clients. CBT aims at having each quality in equal measures. For CBT the therapeutic relationship is the corner stone for the entire therapeutic process. By successfully exhibiting all of the qualities a therapist can build a strong relationship with their client. CBT regards the client as being the only person who is an expert about themselves. However it also recognizes that despite their expertise the client does not have the tools or knowledge in order to build and implement solutions for their problems. As such CBT uses the therapeutic relationship to guide the therapeutic process where as the client provides the information and expertise about themselves and the therapist provides the skills and knowledge about problem understanding and solutions. CBT utilizes what is known as collaborative empiricism, which describes how the client and therapist integrate, test, and attempt to modify the thoughts and behaviors of the client in order to reach the therapeutic goals. Together the therapist and client work towards solving the client’s problems and enabling the client to be self-sufficient after therapy.

    2. Why is it important to have session structure for effective CBT?

    CBT holds a valuable quality in that it has a very no nonsense approach when it comes to therapy. CBT focuses on setting and attaining goals as well as creating a clear and effective method for reaching those goals. This no nonsense approach is reflected in many different parts of CBT even down to the session structure. Session structure ensures that nothing is left out or forgotten from session to session. It also ensures that each session is focused on making progressive steps towards the determined goal. Session structure limits the amount the distractions that could arise during a therapy session and as such attempts to maximize the effectiveness of each session. Session structure ensures that client is making positive steps towards their therapeutic goal in a timely manner. A core principle of CBT is that a person should not be stuck in therapy for an excessive amount of time and proper session structure lends itself to that end. Lastly session structure helps to stimulate a positive and organized therapeutic environment for the client all the while helping to teach them the importance of maintaining order and structure within their lives.

    Reply

    • Lexie Ford-Clottey
      Feb 08, 2018 @ 12:23:44

      Hi Matthew,
      In your discussion of the therapeutic relationship in CBT, I like how you consider and highlight the interactions that occur between the therapist and client as a relationship that has more of a teacher-student quality. By viewing the therapeutic alliance in this lens, it is easier to see how collaboration works its way into the process of therapy. I also think it is important to realize that although clients are experts to their own lives does not mean they have the knowledge or resources to implement this change on their own. This is why the role of a CBT therapist is to provide clients with the necessary tools and techniques, so they can use these strategies to maintain change. I agree that the therapeutic relationship in CBT requires the client and therapist to not only work together but to combine their knowledge/skills into the process of treatment. I also like how you focus on life after therapy for clients, indicating that therapy is not meant to last forever and that clients are expected to utilize what they have learned once therapy concludes. This also hints at the idea that the goal of a therapist is to help clients become their own therapist by the end of treatment.

      Reply

  9. Abbey Lake
    Feb 08, 2018 @ 10:34:25

    (1) What is your understanding of the therapeutic relationship in CBT (include collaborative empiricism in your discussion)?

    My understanding of the therapeutic relationship in CBT is that essentially both the patient and the therapist must continuously work together throughout therapy as a team to reach the goals that the patient has. A CBT therapist helps the patient to prioritize the problems that the patient is having and guide him or her in participation during therapy. A CBT therapist also teaches self-help tasks. An important aspect of the therapeutic relationship in CBT is that the active participation from both the therapist and the patient. For example, the therapist may explain why they want the patient to do a particular task, elicit the patient’s reaction to the task, and then the patient must complete the task either in therapy or as homework. Beck (2011) discusses how one way to strengthen the therapeutic relationship is by helping patients to alleviate their distress. This process often requires showing warmth and empathy, however, the overall intention is to ensure that the patient feels comfortable working with the therapist and that symptoms become reduced as the therapeutic alliance becomes stronger and both the patient and the therapist work together. In other forms of therapy the therapeutic relationship is known to be the primary way to elicit change, however, in CBT the therapeutic relationship is characterized by collaborative empiricism. This is the treatment approach that creates a team- oriented alliance where the patient expresses his/her problems and the therapist works to understand the patient and together they discover maladaptive thoughts and behaviors and work towards positive change. (Wright et al., 2006) discusses how collaborative empiricism holds the patient accountable while also using accurate empathy. I think collaborative empiricism is so important to CBT because it prepares the patient for being able to solve his/her own problems in the future when he/she is no longer in therapy because the patient can reflect upon how he/she was active in solving problems and will have the confidence to apply the skills that he/she has learned previously in therapy. I believe that collaborative empiricism is one of the reasons that CBT is so effective.

    (2) Why is it important to have session structure for effective CBT?

    It is important to have session structure for effective CBT because structuring sessions facilitates treatment goals by helping to express the process of therapy in an efficient and effective manner that both the therapist and the patient will understand. Since CBT relies heavily on collaborative empiricism, structuring sessions is especially important, because it allows patients to know what to expect out of therapy. (Wright et al., 2006) makes an interesting point in mentioning that structuring can help to generate hope in patients. Patients can understand what therapy will consist of and what is expected of them more accurately with session structure. A patient may be feeling hopeless but once they see how therapy is structured they may begin to gain confidence in the process of CBT. Structuring also helps the therapist and patient to collaborate and prioritize in therapy. Session structure keeps therapy organized and helps the therapist and patient to stay on target with treatment goals so that therapy can be as efficient as possible.

    Reply

  10. Allexys Burbo
    Feb 08, 2018 @ 13:18:48

    (1) Within CBT, the therapeutic alliance is a component that contributes significantly to therapeutic outcomes. The idea is that, unlike more traditional views of the therapeutic relationship that emphasize the role of clinician as the vessel of knowledge and insight (unilateral relationship), within CBT both clinician and client work collaboratively. The clinician, through this orientation, acknowledges the client as the primary source of information and attributes insight and change to the individual rather than to “the expert”. Collaborative empiricism, which defines this aspect of the therapeutic relationship, not only emphasizes the collaborative, action-oriented nature of the alliance but also asserts that the integration of evidence based research helps facilitate the skills necessary for thought-behavior change – the goal of CBT. Its primary focus, in this instance, is to identify both maladaptive thoughts and behavior and assess their function in order to ultimately adjust. The notion of collaborative empiricism is the key component of the therapeutic relationship which fosters the overall effectiveness of CBT. In addition to this aspect of the therapeutic alliance, CBT also emphasizes interpersonal skills as a defining characteristic. The notion is that the clinician who exhibits qualities of expertness, trustworthiness, and attractiveness will demonstrate interpersonal skills which may strengthen the therapeutic relationship. Empathy, or the ability to express concern and understanding by validating the clients’ emotions, is another feature of the therapeutic relationship in CBT. If the clinician is able to regard the client in this way, genuinely, it may not only reinforce the relationship but also increase self-efficacy and facilitate positive change. Unconditional positive regard is another equally important aspect of the therapeutic relationship. In this instance, if clients perceive that their thoughts, emotions, and behaviors are not judged, they will be more inclined to be open and honest in the therapeutic setting. While in isolation these qualities are important, within CBT all are essential for strengthening the therapeutic relationship and increasing the potential for successful outcomes.

    (2) As is the case with any therapeutic setting, session structure is an integral component for effective therapy. One of the most essential components of the session will unfold during the earliest phase of therapy in the form of checking-in and assessing client mood and symptoms. This stage not only helps build rapport, but also functions as a means to help gauge the clients “status” (i.e., psychological, emotional, etc.) and ultimately determine subsequent phases of treatment. As CBT is a goal-directed orientation, it is essential that goals are established in the early phases of therapy. With the establishment of goals, setting an agenda will help keep sessions move forward in an effective way. Homework, a unique feature of CBT, is especially important to the collaborative nature of CBT. This component helps client and clinician work through the therapeutic process by integrating evidence-based skills both within and outside sessions – this helps steer the direction of therapy in another goal-oriented way that increases the chance of success. In later phases of CBT, both client and clinician continue to work collaboratively by utilizing an agenda to help assess, review, and formulate problem-solving strategies around specific areas of concern. This feature, in particular, provides structure to the therapeutic process by creating a channel for the client and clinician to redirect components of therapy that might hinder progress. Feedback and summaries, for this reason, are not only important for the purpose of assessing client progress and their application of learned skills but they also serve to encourage the movement of therapy forward. In evaluating aspects of therapy sessions, the clinician is able to discern what is helpful or a hindrance and make the necessary adjustments for effective treatment.

    Reply

    • Aleksa Golloshi
      Feb 10, 2018 @ 08:26:12

      Hey Allexys,

      I really like how you discuss expertness, trustworthiness, and attractiveness in your post! I think these qualities are just as important as knowing fundamental CBT skills because if a therapist does not portray these characteristics their client might not share honestly with them. The client might assume they cannot truly connect with the counselor or that the counselor just “doesn’t get them,” but by expressing these characteristics the therapeutic relationship begins to formulate. You describe positive regard as another important characteristic of CBT, which I too believe is a fundamental skill. This allows the client to further express their thoughts and feelings, which can help the two understand where the client’s maladaptive thoughts and behaviors stem from.

      Reply

    • Abbey Lake
      Feb 10, 2018 @ 16:07:25

      Hi Allexys,

      I enjoyed reading your post – especially the points that you made regarding collaborative empiricism. You did a great job in explaining not just the collaborative aspect of CBT but also the empiricism aspect and what that means to this type of therapy. It is so important to understand that integrating evidence -based research in therapy is one of the major goals of CBT. I agree that this is what helps facilitate the skills necessary for thought-behavior change. I also agree that session structure is an integral component for effective therapy. You explained the early session stage of therapy very well in mentioning that checking-in and assessing client mood and symptoms is an important aspect in this stage of therapy because it has an impact on the subsequent phases of treatment. The videos that we watched in class showed us that the early session stage is focused on discovery and as therapy progresses to the middle and late session stages what was discovered begins to be applied. I think it is important to also acknowledge that assessing client mood and symptoms is an important aspect throughout the entire therapeutic process. An example of how to do this could be what we saw in the video during class, which was when the therapist asked the client, “How would you rate your depression right now on a scale of 1-10?” I think it is especially important to assess client mood and symptoms, because this helps both the therapist and the client to gauge how therapy is going and if things are improving or not.

      Reply

  11. Louis D'Angelo
    Feb 08, 2018 @ 14:11:07

    1. The therapeutic relationship is paramount in cognitive behavioral therapy for establishing and maintaining trust and comfortability in the patient-client relationship. Studies have shown that positive collaborative therapeutic relationships directly influence positive change in the client. Establishing a good therapeutic relationship occurs in the first steps of treatment sessions as well as throughout the session to promote trust. Empathy, warmth, and genuineness applied correctly and at the right times in therapy are key skills in promoting a healthy relationship. Humor can also be an effective technique although Wright emphasizes that this could backfire as insensitive and should be used sparingly when it is spontaneous yet genuine, constructive, or focusing on external problems and not personal weaknesses. Many other techniques are also used such as transparency in communicating conceptualizations and treatment plans, immediacy in directly working on the therapeutic relationship (asking for feedback, catching discrepancies), varying treatment styles in a flexible and sensitive way (considering situational issues, socio cultural background, and diagnosis and symptoms), using affirmations of effort and positive psychology, using psychoeducation in providing coping skills and techniques to record and understand irrational thought, and lastly being collaborative. The term collaborative empiricism in CBT is a term used to describe the collaborative nature of the relationship as well as the empirical method to challenge irrational thoughts and cognitive distortions using evidence based practice of socratic questioning, cognitive restructuring, and guided discovery. Collaboration provides the client with the means to be an active role in their therapy and results in long held positive change. It give the client the knowledge and tools to recover from any relapses in automatic thoughts or emergence of any new problems after termination. This way, the therapeutic relationship is often a teaching or a coaching role providing the client with the knowledge and tools to use after termination

    2. In session structuring, the clinician should provide a framework of each session to make sure that the sessions are efficient while making sure the session is collaborative and client centered. Beginnings of sessions should include establishing rapport, mood checking, updating, review of homework, and prioritizing the agenda. Prioritizing is important here for efficient CBT work because it allows the client the autonomy to discuss issues they feel are most pressing or potentially chronic or interfering. In the middle of the session the client and clinician work on the prioritized problems in a collaborative and psycho educative way often practicing themes such as the cognitive model though discussed topics and establishes homework for intersession periods. The end of the session includes a summary of the work including thought processes, goals, and homework assignments. Summaries are critical for dissolving discrepancies and making sure the clinician is not making any false interpretations. The end of the session also involves the clinician receiving feedback either verbally or through a questionnaire to directly work on the therapeutic relationship and establish good progress. Through a semi structured session, the clinician can make sure certain needs such as proper prioritizing, psycho-education, homework, and feedback are all accomplished in the short amount of time while allowing the client autonomy and control over what is discussed. The clinician also has the ability to adjust pacing. For example focusing on a pressing topic or moving on to avoid rumination over one topic when another problem needs to be addressed.Using the semi structured session and pacing the session as necessary, the clinician can work toward more efficient sessions and more effective cognitive behavioral therapy.

    Reply

    • Stephanie Mourad
      Feb 09, 2018 @ 23:07:07

      Hi Louis,
      I agree with you that the collaborative process should begin in the beginning of the therapeutic process. Without this, the client will not understand the this is not a one-sided therapy but rather therapy that the client can take control of. The client will be able to set some of the goals needed and the client will be allowed to be active. Activity is needed for some treatment and an example could be exposing a client who is suffering from OCD. I like that you used the words empathy, warmth, and genuine. This is what we learned in our 600 class and I think these qualities are very important for therapists. Without these qualities, I don’t that that therapists would be able to connect to their clients on a more human level.

      Reply

    • Abbey Lake
      Feb 10, 2018 @ 15:40:30

      Hi Louis,

      You made some important points regarding the therapeutic relationship and how it is imperative to establish and maintain trust and comfortability. This is so important because in order for a patient to feel as though they can express themselves to their therapist they must be comfortable and feel as though therapy is a safe place to discuss challenging topics. It is essential for the therapist to gain a full understanding of the obstacles that the patient may be facing in his/her day-to-day life so that a successful treatment plan may be developed. If a client is comfortable they will be more likely to share maladaptive thoughts and intense emotions that he/she may be struggling with. Your point that empathy, warmth, and genuineness must be applied correctly and at the right times is also very important to the idea of collaborative empiricism. When expressing empathy it is important for a therapist to be somewhat ambiguous in order to validate emotions in a balanced way that won’t upset the client or negatively impact the therapeutic relationship. Collaborative empiricism is the idea that both the therapist and the client are active participants in therapy. If a client does not feel comfortable disclosing information in therapy it would be very challenging for them to be an active participant during therapy. As we discussed in class, CBT therapists should not challenge emotions but challenge thoughts instead. You also made some interesting points regarding structured sessions. I agree that structuring sessions allows for proper prioritizing and has multiple benefits. It is a good point to mention that CBT is supposed to be accomplished in a relatively short amount of time. Without proper structure the therapy may not be as effective because there may not be enough time for the many important aspects that you mentioned such as psycho-education and feedback. CBT therapy begins with importance on discovery and progresses into application of discovery by the middle to late session stages.

      Reply

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Adam M. Volungis, PhD, LMHC

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