Topic 3: Therapeutic Relationship & Session Structure {by 9/20}

There are multiple readings due this week (J. Beck – 3 chapters; Volungis – 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 9/20.  Have your two replies posted no later than 9/22.  *Please remember to click the “reply” button when posting a reply.  This makes it easier for the reader to follow the blog postings.

20 Comments (+add yours?)

  1. Alyce Almeida
    Sep 15, 2018 @ 11:17:04

    From what we’ve been asked to read, the therapeutic relationship in CBT is highly focused on the collaborative efforts between the client and the therapist. Developing a cognitive alliance helps the client and therapist establish the mutual goals they’d like to see come from therapy. This alliance helps explain the collaborative empiricism within therapy, which ultimately is described as action-oriented, motivated by varies of research. This idea helps promote the basics of CBT: to modify clients thoughts and behaviors. The therapeutic relationship is suppose to promote understanding, guidance, and feedback for both the client and therapist. As mentioned in the text, there are “nonspecific factors” that influence the therapeutic relationship which include Rogerian qualities and interpersonal skills. Providing empathy, unconditional positive regard, and genuineness as a therapist is crucial while implementing CBT structure. Interpersonal skills prove to be also crucial to support the collaborative empiricism, as it represent skills that professionals should be modeling within therapy. These skills include expertness, trustworthiness, and attractiveness. With all of these qualities, therapists have the opportunity to truly benefit their clients and therapy as a whole, but that relies on what I think is most important: the therapist being active! Not only do you need to have these skills, but be able to identify clients appropriately to really maintain the goals throughout therapy. If you’re not “active” as the text likes to say, you can’t really achieve anything. How do you expect to truly However, the client does take some responsibility since they have to be on board with everything in order for the therapeutic process to really prosper. This collaborative empiricism is what I like to call the “glue” in CBT therapy, as it holds all the ideals of what the therapist should embody as professionals but goals they should aim for in the relationship with their client. You can’t get any outcome if all your pieces (goals, session structure, progress, etc.) if you don’t have any glue.

    Session structure is key for effective CBT. How do you expect to have effective therapy if your sessions have no guidance, plan, or outcome? I’d hate to be a client that walks in to a room with my therapist for him/her to have a “whatever” mentality and just be all over the place. Structure within sections provides an outline for your clients to follow, promotes flow throughout sessions, and makes the session beneficial as it provides the crucial necessities to achieve why you and your client are both there: to do therapy! Having an set of tasks to achieve within session helps the therapist better understand their clients needs, so they can therefore help their clients understand their own needs to create goals to modify their behavior(s). Having an agenda, checking in with the client and hearing any updates, assigning/discussing homework, discuss client problems, and provide feedback can help provide an organized platform where individuals could prosper from. I definitely don’t think success can come without structure, and with CBT specifically theres so many factors involved that help influence and promote therapy that not having structure makes it nearly impossible to truly tackle the simple idea of change. Changing from maladaptive to adaptive functioning, with education and understanding, and collaborative methods and strategies to promote this shift in behavior and thought. The real question is: Is CBT really CBT without structure?

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    • Amanda Russo-Folco
      Sep 15, 2018 @ 13:41:24

      I thought your discussion was enjoyable to read because everything you said was true. Everyone would want an active therapist because it keeps the client engaged and they will be on the same page as the therapist (at least that’s the goal). If the therapist was not active, then you are absolutely right, nothing will get achieved. In order for the client to be active, they have to see the therapist become active, and that is how the therapeutic relationship begins. Once they are both on the same page, then the therapist can help the client reach their goals. I also loved how you said that collaborative empiricism is like the glue to CBT. That is a great way of looking at it because it is what holds everything together. I also agree with your discussion about session structure, because CBT would not be CBT without session structure. Session structure and collaborative empiricism are key for CBT.

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    • Deanna Tortora
      Sep 18, 2018 @ 22:29:55

      “I’d hate to be a client that walks in to a room with my therapist for him/her to have a “whatever” mentality and just be all over the place.”

      Alyce, I can’t agree more! I think structure not only allows for direction for therapy, but it also gives clients hope that their distress can be dealt with in a logical and methodic manner. As a client, I would feel reassured seeing that my distress can be worked through in a specific structure. If I went to a session where there was no structure at all I wouldn’t feel very confident as I wouldn’t’ see how my distress would be worked on. With no structure I might even feel like my therapist is doing the bare minimum. But with CBT structure, a client can see how their therapy is mapped out and how their distress and problems will be addressed. From a client perspective I can easily see how structure would be preferable.

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    • Marissa Martufi
      Sep 19, 2018 @ 21:37:25

      Alyce, I really liked your discussion about session structure. I like how you ending with the question “is CBT really CBT without structure?” – This is such a valid point. I think it is easy for people (outside our profession) to assume that therapy is simply just sitting on a couch or in chairs and talking about what is going on. This is also a potential stereotype that clients beginning therapy may have. However, CBT is so much different than that, and what makes it effective, is the way it uses structure to provide feedback, teach and practice problem solving skills, and work towards achieving goals for therapy. For client’s beginning CBT, this structure is likely reassuring to them and like you said, also allows for a flow through the sessions. I also agree the structure in session is what makes these sessions beneficial for the client and therapist.

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  2. Amanda Russo-Folco
    Sep 15, 2018 @ 13:32:33

    My understanding of the therapeutic relationship in CBT is that it is very important to establish trust and rapport with patients from the very first session. It is important to create an environment that is safe for the patient, so the patient can feel as if they can trust the therapist fully. This will lead the client to reveal more information to the therapist. If the therapist and client have a positive alliance, then the outcome will be positive as well because establishing a therapeutic relationship is crucial for therapy. Having a therapeutic relationship is beneficial for the client overall. Without a therapeutic relationship, the session will not be able to build or improve and the client will not be satisfied because the client will not see any improvements. This is how clients can become discouraged and not want to go to therapy. This could affect the client and the way they view things in their life. It could possibly make the situation worse. According to Beck, there are several factors that must be met. The therapist must demonstrate good counseling skills and accurate understanding, share a treatment plan, make decisions collaboratively, look for feedback, change styles depending on the client, and help the patients solve their problems and alleviate their distress. These are key factors that need to be considered to establish a therapeutic relationship. It is also important to remember that the therapist and the client are both active participants because it is a collaborative process. This is the most successful way for CBT. Collaborative empiricism is an action-oriented therapeutic alliance that is driven by research that integrates, tests, and modifies clients’ thoughts and behaviors. This is a CBT specific factor because it is important to identify maladaptive cognitions and behaviors and then “test” for their empirical validity. There are three sequential sections that highlight the key specific factors of collaborative empiricism which is therapist-client activity level, client-specific factors, and conceptualization and treatment. There are also nonspecific factors (common factors) such as Rogerian qualities and interpersonal skills. Rogerian qualities include empathy, unconditional positive regard, and genuineness. Interpersonal skills include expertness, trustworthiness, and attractiveness. These are all important factors that contribute to CBT because this is what makes CBT different than the other therapies.

    It is important to have session structure for effective CBT because a client would want a therapist who has things in order, rather than someone who is all over the place and does not know how to keep things straight. It is important to have a session structure to be able to have goals for each session, so the sessions could improve and reach their ultimate goals. If the therapist does not have a session structure, then there would not be any goals for the sessions and the sessions would just be going with the flow, and not improving. This would not be effective for CBT because it is very important to have goals and treatment plans and to follow them, so the client can be healed and be able to handle their situations on their own. Structure session is important from the very first session to the last session in CBT. Clients seek comfort in structured sessions because it shows that therapy might be able to provide some relief to their distress. It also provides direction for the therapist and for the client. If I was a client, I would not want to have a therapist that is all over the place. It would help me feel better if I had a therapist who had a plan and goal for me to receive the care that I need. I would only want to get better, not worse. Also having session structure can help the therapist have a better understanding of their individual clients and their needs and can also help treat them as best as they can. Therefore, it is very important to have session structures and establish a therapeutic-alliance to help clients succeed in their everyday functioning and to relieve their distress.

    Reply

    • Sam
      Sep 18, 2018 @ 11:47:29

      Amanda,
      you mentioned in your response to therapeutic alliance that a client may become discouraged if they are not seeing improvements. I like this idea because I too, noted this in my response to therapy structure. But I did not think of it under therapeutic alliance. I agree whole heartedly that, when there is no positive rapport between client and therapist, that even if you ignored that and just focused on the therapy modules, you would still find that the client is most likely feeling discouraged and improvements will not occur. Thanks for sharing!

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  3. Mikala Korbey
    Sep 16, 2018 @ 17:18:11

    My understanding of the therapeutic relationship is that it is one of the most important things for good client outcomes in therapy. The therapeutic relationship is a collaborative process between the therapist and the client, and both individuals are active participants. A positive alliance between therapist and client leads to a better patient outcome. A good therapist displays empathy, unconditional positive regard, and genuineness, as well as, displays strong interpersonal skills. A CBT therapist is very self aware of themselves and their automatic thoughts. It is important for the therapist to be aware of how they are displaying their emotions about the situation because nonverbal cues that display negative emotions could negatively impact the therapeutic alliance. Additionally, the therapist should practice “vigilant empathy”, which requires taking a step back and reminding yourself of where the client is coming from. Therapists should practice collaborative empiricism, which is a relationship that is action-oriented, and supported through a variety of research. If there is not a good therapeutic relationship, it is going to be very difficult to do effective therapy. The basis of CBT is to change clients thoughts in order to change their behaviors. If the client does not feel like they have a good relationship with you, they will be far less likely to open up about their issues.

    Having structure during therapy is a key component of CBT. Maintaining structure is best achieved by setting an agenda with your clients. An agenda often reduces a patient’s anxiety because they will know what to expect in the session. Additionally, it makes therapy more understandable and requires that the patients help to take action and responsibility in their treatment. Structure often provides the client some comfort and hope that therapy will work for them, while also allowing the therapist to show that CBT is a collaborative process. The therapist will create an agenda before meeting with the client, but should go through it with the client to ensure that they are satisfied with how the session will go. Agendas allow for organized therapy so both parties can stay focused and makes most of the limited time therapists often have. The items on the agenda should be directly linked to the treatment goals in order to ensure that appropriate progress is being made and is related to the goals that the therapist and client set. Although having structure is important, it is crucial to not have too much structure because need to allow for flexibility. If there is no flexibility, the client may feel as though they cannot stray off track if something has come up that they feel they need to talk about. Finally, structure shows that you know what your talking about and displays confidence in your ability to treat your client.

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    • Sam
      Sep 18, 2018 @ 11:42:54

      Miakala, I like that you mentioned the need for flexibility. CBT is regarded as highly structured, but I agree with you, that sometimes, something may come up in a clients life that should be discussed even if it does not directly correspond with what the session was supposed to look like on that day. Random events happen in life, and because CBT focuses on the “here and now” room should be left in CBT structure for everyday life events, as they may interfere with treatment goals. Nice thought!

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    • Amanda Russo-Folco
      Sep 19, 2018 @ 14:34:29

      I believe you hit all the important points in your discussion because everything you mentioned and talked about is true. I liked how you talked about nonverbal cues as well because sometimes people are unaware of how they are acting, and it is very important to be conscious of our actions, whether it is verbal or nonverbal cues. Having a great relationship with our clients is what clients are going to remember the most. It is the relationship that is going to make the clients want to keep coming back. I also liked how you talked about having some flexibility within the sessions. It is important to have some flexibility because some clients will have good and bad days and it is important to let them know its okay if they get off track sometimes. Therefore, having an agenda can help the sessions improve because you can start back to where you left off from. All in all, it is important to have structured sessions, so the client and the therapist can be on the same page.

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    • Marissa Martufi
      Sep 19, 2018 @ 22:20:46

      Mikala, I enjoyed reading your discussion post. I agree that although structure is an important component of CBT, it is important to also have a bit of flexibility. Although a structure is beneficial and important to effective CBT, there is also a need to be flexible at times. Sometimes things come up, such as a problem or event, that effects the schedule or structure of therapy and requires the client and clinician to stray from their agenda to address the problem. I think as a new therapist, this is important to remember. I know for me personally, I will likely be nervous as I begin my career and will possibly feel that I must stick to or follow a set structure, therefore I might be a bit nervous to stray from that. However, I do agree that it is important to not have too much structure or avoid that flexibility component. This does play a role in the client-therapist relationship too. I think it’s about finding a balance between structure, and conforming therapy session and structure to meet the needs of your client.

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  4. Sam
    Sep 18, 2018 @ 11:37:54

    Contrary to previous criticisms of CBT ignoring the role of the therapeutic relationship, it is quite evident, even from the earliest texts of CBT, that this model places great emphasis on the importance in establishing a positive therapeutic rapport. In just his first few sentences about therapeutic alliances Volungis (2018) expresses that, the therapeutic alliance strongly influences desired treatment outcomes. The characteristics and actions of the therapist are important in creating a sound therapeutic alliance. By this I mean that, a therapist should incorporate Rogerian qualities in treating their clients with respect, empathy, unconditional positive regard and genuineness. A therapist should be cognizant of how their own perceptions, characteristics and actions, affect their ability to create and maintain a therapeutic relationship. Additionally, it is crucial to understand that the treatment process begins from the first session, therefor, a therapist should work to build trust and rapport with their clients the second they walk through the door. Moreover, creating a therapeutic alliance means, creating collaborative empiricism. The therapist and client should work together to establish goals and desired treatment outcomes. Additionally, both the therapist and client should work collaboratively to identify thoughts regarding their treatment goals, and potential barriers in reaching them. Building collaborative empiricism is essential because it allows both client and therapist to explore possible solutions and determine what the client is willing to try in and outside of the therapy session. A strong therapeutic alliance with a collaborative nature is essential in CBT therapy as it may help treat a vast amount of behavioral and emotional disorders through identifying automatic thoughts and core beliefs.
    Moreover, effective CBT also includes structure. Simply put, structuring sessions is the most effective and efficient way of getting the work done. The basic premise of CBT treatment is to establish goals, therefor rather than letting a client talk freely about their life, maintaining structure by setting goals and desired outcomes for each session allows therapy to run smoother and more effectively. For therapy to be effective, each session should utilize specific techniques and concepts, and if the therapy is not structured, treatment goals may fall behind and overall treatment outcomes may be unfavorable. Additionally, a structured therapy session may be crucial to the client, as they often come into therapy in a helpless state. Structure in this case may help the client (and therapist) to know what to expect from in each session so they can assess the treatment they will receive and so they can be better prepared for therapy by understanding how weekly sessions work. Especially in this case, if a client is feeling helpless, session structure can be a boost of hope. This is because usually the first sessions are structured to instill hope by creating goals and setting an agenda. From my point of view, a structured therapy session is almost no different from being on a diet or exercise program. Similar to CBT structure, an exercise program includes certain tasks and goals that should be completed either daily or weekly. Having these goals, and completing them in both CBT or an exercise program, shows the client/person that what they are doing is effective. If the goal of the exercise program is to lose a certain amount of weight and gain a certain amount of muscle mass each week, and the client sees this happening, they are more likely to continue the program. In CBT, if a client is noticing substantial changes in their thought processes after each session, then they too, are more likely to return to sessions and work harder.

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    • Deanna Tortora
      Sep 18, 2018 @ 22:43:22

      “Contrary to previous criticisms of CBT ignoring the role of the therapeutic relationship, it is quite evident, even from the earliest texts of CBT, that this model places great emphasis on the importance in establishing a positive therapeutic rapport.”

      Sam, I like how you mentioned one of the common and erroneous critiques of CBT. Anyone that has actually read and learned about CBT can easily see how important the therapeutic relationship is. The therapeutic relationship is so integral to therapy that CBT theorists explain the importance of developing the therapeutic relationship even at the initial session! Throughout our readings many of the theorists have emphasized different ways to improve or build upon the therapeutic relationship. They even explain that it is one of the foundations of effective CBT! Which is why the criticisms are absolute malarkey! I’m very glad that you had mentioned this component because it is quite evident that the therapeutic relationship is a key component in the effectiveness of CBT. Criticizing that CBT ignores the role of the therapeutic relationship means one is completely ignorant to the actual practices of CBT.

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  5. Becca Green
    Sep 18, 2018 @ 17:44:41

    After reading the sections on therapeutic relationships in CBT in both Volungis (2018) and Beck (2011) it seems as though the therapeutic relationship starts with building trust with the client. If you are able to build trust with the client then your foundation is set for the therapeutic relationship and you can begin the collaborative work towards the client’s goals. Collaborative empiricism and session structure is what makes CBT different from other types of therapy. This forces the therapist and the client to equally work together in creating and understanding the goals of therapy and ensuring that progress is being made. In order to do this there must be a strong therapeutic alliance between client and therapist, as there may be times in which the client becomes discouraged or feels as though they are not making enough progress. This also allows the therapist to better understand the client through skills like empathy and the interpersonal skills mentioned in Volungis’s text (p 17-18, 2018). By having a strong understanding of the client (i.e. their negative automatic thoughts, core beliefs, and motivation) and having a strong therapeutic alliance the therapist can more accurately assess progress and how to most effectively push the client to continue to work on their goals. It can also make the client more comfortable with speaking out when they think there may need to be an adjustment to the treatment plan if there is a strong therapeutic alliance. With a strong therapeutic alliance both parties are going to be more motivated to make changes and actively engage in therapy.

    Structure is vital in CBT as this is what sets the client up for the most success outside of counseling. In this era of managed care most insurance companies only allow a certain number of sessions for therapy to be completed in. While there are some ways to get around this in extreme cases, more often than not you will have an allotted number of weeks to work with the client. Structure allows the therapist to structure the sessions in order to get the maximum relief in distress and the maximum learning for clients to be able to handle future distress on their own. The therapeutic alliance needs to be strong in order for the therapist to understand how to best put together a treatment plan that works in the allotted time and also works for the client. Basically, session structure allows the therapist to guide, teach, and work with the client to reduce distress and have the client become their own therapist in the shortest amount of time. By that I do not mean that you will rush through the process, but instead of having a single client for 3-5 years it may last only a few months. There is always room for adjustment within this structure and the treatment plan to ensure that the client is still progressing at a comfortable rate.

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    • Alyce Almeida
      Sep 18, 2018 @ 21:06:14

      Becca, your first response to the question so very well executed. I liked how you you described collaborative empiricism and the therapeutic relationship as a key to motivation for therapy. Specifically, I liked how you mentioned that with that, a client will be more likely to speak up around their treatment plan. I didn’t even think about that at all in regards to my response, which makes me reflect back on the importance around open communication with your client as a clinician, and how this collaborative approach impacts more than what we might assume.

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  6. Deanna Tortora
    Sep 18, 2018 @ 21:57:19

    (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 it is a relationship built on things such as trust, empathy, positive regard, honesty, and the combined goals developed by client and therapist for client betterment. In the therapeutic relationship, client and therapist collaborate throughout the course of therapy to help the client in specific ways. Whether it be developing adaptive coping skills or simply exploring a traumatic event with the careful guidance of a trained therapist. Regardless, (successful and effective) therapy is a two-person tango. This is why it is important to establish a good therapeutic relationship from the very first session and maintain/develop it in following sessions. Establishing trust and rapport allows for a safe environment for the client (and therapist) to work in. If the client feels like the environment is conducive not only will they continue to engage in therapy but they are more likely to open up to the therapist and collaborate with them. Without a good therapeutic relationship clients could feel it is not safe to share or work with a therapist or even discontinue services all together. A good therapeutic relationship helps facilitate therapy as it allows for both client and therapist to work together on therapeutic goals. This very fact refers to collaborative empiricism where therapist and client tale action together to integrate, test, and modify client thought and behavior. This means it is supported by research that assessments and interventions are effective in therapy, along with integrating client specific behaviors and cognitions for modification. Therapists identify the maladaptive thoughts and behaviors and test them for their validity and or utility, showing clients how their thoughts or behaviors are maladaptive and correcting them. It is important to note that there are nonspecific factors (e.g. empathy, unconditional positive regard, appropriate/warm body and verbal language, validating client thoughts and feelings) and CBT specific factors (e.g. collaborative empiricism, therapist-client activity, client specific factors, conceptualization/treatment) that contribute to the therapeutic relationship. All of these factors interact either with each other, with client and therapist, and/or with the therapeutic relationship or therapy services overall. There are many complex factors that contribute to the therapeutic relationship and therapy itself. Therapists should be careful to do whatever they can to develop a healthy and positive therapeutic relationship (i.e. focusing on appropriate use of nonspecific factors and integrating CBT specific factors). In all, the therapeutic relationship is important for client and therapy success. But it depends on therapist and client factors, as well as CBT factors, in order to be successful.

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

    It is important to have session structure for CBT because without it therapy would be a mess and not at all therapeutic! Most of the structure for CBT relies on the goals that therapists and clients set. Without these goals, or attempting to achieve these goals, therapy would be unmoving and as good as the “therapy” achieved by scarfing down ice cream on the couch. (While fun and sometimes a temporary fix to our negative feelings, it is not at all therapeutic). If there is no direction to therapy then clients will remain distressed. Structure and goals can provide clients with the hope that their distress can be worked on and relieved through therapy. CBT structure also allows for the consistent opportunity to build up the therapeutic relationship that drives therapy. Whether this be by demonstrating how the therapist is trustworthy and professional, turning clients on to CBT and how effective it is and can be, and/or by demonstrating how CBT and sessions structure is collaboration based, and allows for clients to be active agents in their therapy while being guided by a professional. CBT session structure also facilitates direction and aids in working on the goals set by client and therapist. Without structure there would be no direction and no real effective way to work towards these goals. Session structure also allows for flexibility and changes that are client specific in intensity or need. If a client needs a more rigid schedule this can be accommodated, or if a client needs a session to explore some traumatic experiences or current stressors, this can also be accommodated for in a session. Session structure deals with client distress more head on and compartmentalizes the specific parts or causes of the distress. Since this is the more direct path to treatment, isn’t it our ethical duty as therapists to use CBT structure and use client (and therapist) time effectively, without prolonging distress as unstructured “therapy” would entail? (This is a rhetorical question. We all know the answer is yes, or we wouldn’t be in a CBT program!)

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    • Mikala Korbey
      Sep 19, 2018 @ 18:40:50

      Deanna, I really like how you emphasized that the structure of the session needs to be based on the client’s need. I think it is important that you explicitly mentioned that the schedule could be more rigid if that is what the client needs. I feel like it is usually glossed over that the client may need a more rigid schedule and usually people just talk about how the client may need more flexibility. And to comment on your rhetorical question, I love that you mentioned this! I had never really considered it in that way, and really appreciate that you brought it up. I agree that it is our ethical duty to use structure and time effectively during treatment. Really great post!

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  7. Melissa Pope
    Sep 19, 2018 @ 12:52:22

    The therapeutic relationship in CBT, like with any strong relationship is built on a solid foundation of trust, openness, honesty, and safe, strong communication. To build such a relationship, theorists have created basic principles that, if established will allow for therapy to become more effective and fluid.

    The client, therapist relationship is described as an “alliance” because both parties should be equally invested in the goals that are wanted to be achieved. The quality of such investment by all parties involved, dictates the quality of the relationship or “alliance”, which will either have a positive or negative outcome. Creating a strong alliance, will also foster the successfulness of collaborative-empiricism within therapy.

    Collaborative empiricism is the action oriented relationship based on empirical evidence that modifies client’s thoughts and behaviors through the integration of treatment plans, tests and working together with client’s to discuss goals.

    Empirical evidence shows that if a therapist is able to balance particular qualities and treatment elements it aids in easing client’s distress and the formation of a mutual and fiduciary relationship. The treatment elements are broken down into non specific and specific factors. Non specific factors include therapist qualities such as empathy, unconditional positive regard, genuineness, and interpersonal skills. Whereas, specific factors focus more on the client; their presenting symptoms, their environment, and their socio cultural factors, that influence their thoughts, behaviors, core beliefs and values. It is also important for a therapist to keep client activity level high by engaging them throughout each session and all phases of the therapeutic process. Engaging clients instills value, trust, and openness in the “alliance”, while also strengthening communication skills.

    The importance to have session structure while conducting CBT, because it creates a comforting and trusting environment. This type of environment will ease client’s distress and aid in the effectiveness of the therapeutic relationship. Each session can be broken down into stages (pre-session, early session, middle and late session). This helps the therapist stay organized and focused, while also allowing the client to know what to expect, and feel valued, because they have an equally important role in how each session plays out in accomplishing goals.

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  8. Jayson Hidalgo
    Sep 19, 2018 @ 18:09:35

    My understanding of the therapeutic relationship in CBT is that it is a fundamental quality that can completely affect the outcome of therapy. From the text, collaborative empiricism is defined as an action-oriented therapeutic alliance driven by research that integrates, tests, and modifies clients’ thoughts and behaviors. In other words, the therapist and client work together throughout therapy to assist the client in completing his or her therapy goals and identifying the client’s cognitive distortions and understanding the concept of how thoughts can affect his or her emotion/behavior. In order for the therapist to help the client and for the client to help himself or herself, an alliance needs to be created for this process to facilitate. The therapeutic relationship in CBT is very important and we simply cannot ignore the negative effects of a therapeutic relationship. If the therapist fails to set an adaptive therapeutic relationship with the client at the start and thus the therapeutic relationship is a little unstable or negative, then the therapeutic relationship can cause harm to the client. The client will not obtain effective outcomes if the therapeutic relationship is not well. I always thought developing a therapeutic relationship was pretty easy because it essentially is just being very nice, very respectful, and very caring towards the patient. However, I was just thinking that maybe developing this alliance can be a little bit more complicated. I may be wrong about this, but even though you possess all these effective qualities of being a competent counselor, it does not mean it will result in a good therapeutic relationship because the other half of the alliance concept depends on the client. For instance, the therapist and the client need to be on the same page or same level. In the beginning of therapy, the therapist displays extreme warmth towards the client and this client is not used to be given tons of warmth so it may cause the client to feel intimidated or uncomfortable since this is new behavior towards them. Thus, the therapist needs to be aware of his or her elevated warmth personality and maybe tone it down a bit. What I am trying to say is that every client is different and thus a therapist needs to adjust how they interact with these different clients, I believe once this occurs, then a therapeutic relationship can be developed that works for the both of them.

    It is important to have session structure because it benefits the therapist and client and it essentially facilitates therapy. Focusing on the therapist, session structure can benefit him or her by helping develop a therapeutic relationship with the client. One of the qualities for an effective counselor is attractiveness, a therapist can be attractive if he or she knows what he or she is doing in the therapy session which staying organized can help do. If a client is aware or sees his or her therapist organizing what will happen in the session then the client will feel comfortable knowing he or she is in capable hands. Another benefit for the therapist is having a session be structured can help a beginner therapist feel more organize and help them to feel comfortable about what he or she has to do in the session. Session structure can also help the client as it can help ease the client’s anxiety if he or she is nervous about therapy since session structure allows the client to know what to expect in the session. This can be seen when the therapist and client both collaborate on organizing the therapy agenda, the client will feel more in control about what to expect and the more control an anxious person has over a situation, the less anxious he or she will feel.

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    • Mikala Korbey
      Sep 19, 2018 @ 18:51:47

      I really like how you mentioned that the relationship needs to involve both parties being on the same page. That reminds me of the idea that the therapist needs to meet the client where they are at. If the therapist just assumes the client is ready to talk and they aren’t, that will lead to negative effects. And vice versa, if the therapist thinks the client is not ready to talk but they are, that could also lead to negative effects. For example, if the therapist thinks the client is closed off, they may approach therapy differently and may make the client feel as though they won’t have a chance to open up about what is bothering them. I agree that it is so important that the therapist meets the client where they are at.

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  9. Marissa Martufi
    Sep 19, 2018 @ 21:13:33

    Something that has really stuck with me from my first semester of grad school, after taking PSY 600, was the importance of a strong therapeutic relationship in CBT. Reading these chapters has also furthered my understanding on this relationship. The therapeutic relationship involves both the client and therapist, and is impactful or influential on the outcome of therapy. Like Dr. Volungis mentioned in chapter 2 of his book, the therapeutic relationship is not the only component or influencer of change in therapy or the outcome of therapy, but it does play a critical role in the process. The therapeutic relationship, when successful, develops an alliance between the client and therapist, as well as collaborative empiricism which is described as an action-oriented therapeutic relationship where both the therapist and client work together toward mutual, or desired goals and outcomes for therapy. Although this relationship sounds like something that might be ‘common sense’, it is important to consider that this relationship involves more than just the client feeling comfortable with the therapist and vice versa. I think it is easy to assume that the therapeutic refers to the client simply being able to openly talk to the therapist in session, and feeling comfortable or trusting in their ability to do so. However, it is important to understand that the therapeutic relationship refers to a collaboration between the therapist and client. Together, the therapist and client must have a strong, trusting, relationship in which they are working towards goals, or outcomes for therapy. This alliance allows clients and therapists to create goals for therapy together, and also work together to achieve these goals. Rogerian qualities and interpersonal skills are some of the critical skills that support collaborative empiricism and the therapeutic relationship in CBT. It is important to remember that most clients are seeking therapy out of a desire to change or seek help from an ‘expert’. Qualities such as empathy, genuineness, and unconditional positive regard are important skills for therapists practicing in CBT. In order for CBT to be effective, clients should be able to gather a sense of these qualities from their therapist. (After all, no one wants to spend time in therapy with a therapist who is not genuine or empathetic to their own personal experiences, thoughts, and emotions.) Therapists should also obtain interpersonal skills which include attractiveness, expertness, and the ability for clients to have trust in them. These skills are critical to the therapeutic relationship. Without the therapist role in this relationship, there is no formal accountability or guiding figure for clients. I think this is something that I always try to keep in mind. Without the role of an expert or trusted, empathetic, and motivating therapist, the client may not benefit from therapy or may have difficulty reaching their desired outcome. Using and implementing supported approaches and skills can produce positive outcomes for both client and therapist. Skills or factors such as interpersonal skills and Rogerian qualities, are important in understanding and implementing a successful and effective therapeutic relationship.

    Along with a therapeutic relationship, session structure is another important and effective component of CBT. Dr. V always mentions how anyone can sit on a couch and listen to a client talk about anything, or talk about their week in a ‘therapy session’. That is not actual therapy. Without a structure or a ‘plan’ for therapy, it is easy for therapy just to simply be a session of the client talking while the therapist listens and makes appropriate comments. However, no real progress is likely being made through this. What makes CBT different and effective, is its unique structure, as well as the guidance and structure it provides client’s to reach designated goals and outcomes. CBT is designed to address client’s presenting problems and also teach clients the skills to resolve these issues or work through them, outside of the therapy session. In order to achieve these outcomes, an organized structure for therapy sessions is needed. This includes an ‘agenda’ or a plan for each therapy session. This allows for organization, as well as guidance towards moving through the phases of therapy, and working towards achieving the goals set for the client and client outcome. The idea is that client’s do not remain in therapy forever, but eventually, with the help of an expert therapist, gain the skills and ability to implement these problem solving skills, independently, outside of a therapy session. This can only be done with structured therapy sessions.

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Adam M. Volungis, PhD, LMHC

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