Topic 3: Therapeutic Relationship & Session Structure {by 2/4}

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 2/4.  Have your two replies posted no later than 2/6.  *Please remember to click the “reply” button when posting a reply.  This makes it easier for the reader to follow the blog postings.

64 Comments (+add yours?)

  1. Althea Hermitt- Mcpherson
    Jan 30, 2021 @ 04:03:07

    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)?

    The therapeutic relationship or alliance in CBT focuses on collaborative empiricism where the therapist and the patient work together to investigate and establish goals for treatment because clients are not passive in CBT. Clients and therapists work together to identify maladaptive thoughts and behaviors. Subsequently, clients are able to examine the rationality, reliability, and usefulness of these thoughts and behavior through personal experimentation and observation rather than by coaxing by the therapist. Nevertheless, therapy client activity level is another important factor in the therapeutic relationship in CBT that will fluctuate and decrease over time depending on the phase of therapy. At the beginning or early phase of therapy, the therapist will guide the way however, the therapist’s level of activity will decrease towards the middle phase of therapy and the client’s level of activity will increase towards the late stage of therapy as the client becomes a protege where they are more autonomous.
    Client-specific factors are also very important to the CBT therapeutic relationship. It is believed that certain client-specific factors can be a challenge to the therapeutic relationship. These factors include presenting symptoms, environmental stressors, and sociocultural factors. Certain presenting symptoms and characteristics of the client can be challenging to the building of the therapeutic alliance for example clients who are depressed might be prone to being low energy and reluctant in expressing their thoughts and feelings. Therefore therapists might find this difficult to deal with. Therapists would need to focus on being self-aware of their demeanor, thoughts, and feelings and be proactive in adjusting their approach to the client. Therapists should avoid labeling their clients because the therapist will only see that label and not the client, which can cause a detached therapeutic relationship or the client could act according to the therapist’s expectations. On the other hand, the therapist could give up on the client due to labeling because of the thinking that the client is afflicted with this disorder and therefore won’t change. Hence the therapist may lose hope for client improvement which could become evident to the client. Another important factor that may affect the therapeutic relationship is the therapist’s judgment about a client’s presenting problem, however, as a beginning therapist, we are reminded to provide vigilant empathy where the therapist should reflect on the client’s background and try to understand why the client would engage in certain problem behaviors. As people, we are prone to biases, judgments, and prejudices however we need to put on a therapeutic lens and emulate unconditional positive regard.

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

    Session structure is important in CBT because it allows the clients to feel comfortable and hopeful since structure helps to ease clients’ level of distress and anxiety. Based on the principles of CBT, having a session structure helps the therapist to be goal oriented and focused on the problems that are pertinent in order to develop thoughtful goal-directed interventions. CBT is time sensitive due to the limited number of approved sessions therefore having a structured session will provide guidance and direction for both the therapist and the client to ensure goals are being met. Session structure socializes the client to CBT and shows how they are both actively participating in the therapy, which will later be helpful to the client during late sessions as they will feel more autonomous. It will also help the clients to understand and be able to replicate the collaborative nature of CBT. Having a good session structure allows the therapist to be seen as an expert. It also helps with the therapeutic relationship as the therapist is perceived as trustworthy, competent, caring, and genuine.

    Reply

    • Beth Martin
      Feb 02, 2021 @ 04:33:38

      Hi Althea!

      I didn’t really focus on client factors in my discussion post, so I enjoyed reading your summary of how they can affect the therapeutic relationship! I think sociocultural factors are something that we should all be especially cognizant of (as a worrying amount of the current guard that I’ve had the absolute *joy* of working with seem to be unable to do so). Understanding that your own personal cultural and social rules/morals/experiences etc. are not necessarily shared by your client seems to be a potential stumbling block for not developing a solid therapeutic relationship. I can’t imagine I’d be overly trusting of a collaborative effort if the professional I’m working with doesn’t understand that my upbringing/background was different to theirs, and therefore the assumptions they’re making about universality don’t apply. I’d also be interested to see any research on how sociocultural client factors also need to be taken into account re: therapists’ demeanours/body language too!

      Thanks for posting, and I hope you’re managing to stay warm!
      Beth

      Reply

    • Pawel Zawistowski
      Feb 02, 2021 @ 15:45:03

      Althea,
      I completely agree that as therapists, we should avoid labeling the client, and being judgmental. In a way, I believe it can come off very condescending and be discouraging towards the client. It would be inappropriate to do so and both of these actions may lead to a weakened self-image. When communicating a diagnosis, we should recognize that it may be a sensitive topic for certain clients and therefore should take caution when we provide the client such information.

      Reply

    • Anne Marie Marie Lemieux
      Feb 03, 2021 @ 17:21:17

      Loved your comments Althea! The word investigate jumped out at me. I think it was smart to note the process of investigation prior to goal setting. It is certainly an important component, as you can’t set goals if you don’t know what the target is. I liked how you laid out the continuum of the therapeutic process ending with autonomy.

      Reply

    • Michelle McClure
      Feb 03, 2021 @ 19:38:27

      Hi Althea! I liked how you mentioned in your post that session structure made the therapist come across as more competent and expert. I had not thought of that in my response but it is so true. The way I put it in my post was that the session structure is what makes therapy different from a chat with a friend. The structure also makes the sessions feel more professional. The structure of a CBT session really has a lot of effects that are not quite as obvious at first glance but are very important to having a productive session. Have a great weekend!

      Reply

  2. Beth Martin
    Feb 02, 2021 @ 04:27:13

    My understanding of the therapeutic relationship in CBT is that it is, essentially, crucial if one wants to have any success in either guiding it or going through it. Also referred to as the therapeutic alliance, this relationship between clinician and client focuses on working together to develop treatment goals and methods for meeting them. The therapeutic relationship, therefore, requires both the clinician and the client to identify maladaptive behaviors and faulty cognitions, through the use of empirically supported measures and assessments. Collaborative empiricism plays a large role here, in that clinicians use methods that have been researched and are therefore empirically backed to be beneficial. This research has shown that a strong client-clinician relationship maps directly onto treatment outcomes. Ideally, both remain fully invested and present throughout the course of CBT, making it a group endeavour, which I imagine leaves a client feeling fully supported and understood.
    Many factors influence the therapeutic relationship, including non-specific and CBT-specific factors. These are factors that are used either across many different forms of therapeutic approaches, or only in CBT respectively. Non-specific factors include Rogerian qualities and interpersonal skills. Rogerian qualities are an umbrella term for tools all good clinicians should have in their toolbox: empathy (and thus no pity), unconditional positive regard, and genuineness. Importantly, empathy must be both verbal and non-verbal during CBT, and clinicians must avoid making assumptions on how clients are feeling. Timing is incredibly important to empathy too; in order to build a strong therapeutic relationship, a clinician must take care not to inadvertently endorse and reinforce any maladaptive thoughts an individual is expressing (e.g. nodding at the wrong time). Genuineness must also be self-measured, in order to not come off as overly genuine, and therefore seeming insincere. Interpersonal skills refers to another set of skills that most therapists (hopefully) possess: expertness, trustworthiness, and attractiveness, which are well understood to help develop therapeutic rapport. Thus, a stronger, positive therapeutic relationship is developed, relying on strong rapport and clients feeling like they are being listened to by a professional.

    Another factor that plays into the therapeutic relationship is therapist-client activity level. CBT is bi-directional, and requires input from both parties. Expectations, provided they are set realistically and early, helps build a “team effort” relationship from the beginning. This activity level for both parties waxes and wanes throughout the various stages of therapy; therapist activity is high during the early phases, as CBT is introduced, but decreases moving forward. Client activity is converse of this, with clients encouraged to become more active and autonomous in their changes, needing less guidance from the therapist or clinician. Overall, the therapeutic relationship is the next “stage” of therapeutic rapport: it is taking that goodwill from a client and using it to build a back-and-forth, collaborative effort in order to effectively deliver CBT.

    Session structure is hugely important for CBT, but it is also important to be flexible with it. Clients traditionally want and need structure; they need to know what is expected of them and when, and said structure gives a therapist an air of knowing what they are doing (though hopefully it is not just an air). Individuals with anxiety, for example, may find a lack of schedule or structure adds to their anxiety, which certainly won’t help treat said disorder. Structure itself means that a clinician has a plan that is goal oriented, and that it is focused on specific problems presenting from the client. Pre-session, early session, middle session, and late session each provide important information that gives insight into a client’s thought process and issues, which in turn helps build the therapeutic relationship (as the client is hopefully seeing progress from information being gained). Structure also helps make efficient use of time, allowing a clinician to set themselves specific aspects to be hit in each session without spending too much time on any particular stage. Overall, structure keeps CBT consistent, making sure that a client knows what to expect each week (which may be especially helpful for those nervous or resistant to therapy, removing the “what if?” aspect of mysticism that often accompanies it).

    Reply

    • Pawel Zawistowski
      Feb 02, 2021 @ 15:53:10

      Beth,
      I liked how you point out that lack of structure can increase a client’s anxiety. It would be totally unprofessional and inconsiderate to our clients if we did not provide them structured therapy. It is perfectly reasonable to think that lack of structure may lead to increased anxiety because our clients would not know what to expect. Additionally, they would question the expertness of the therapist. I believe that lack of structure is a sign of being unprepared and incompetent as a professional.

      Reply

    • Althea Hermitt- Mcpherson
      Feb 03, 2021 @ 01:40:44

      Hi Beth I liked that your explanation of collaborative empiricism and how you emphasized that it plays a role in Clinicians using methods that have been researched. I also liked that collaborative empiricism allows the therapist and the patient to work together to investigate and establish goals for treatment. Instead of telling the client what to do, because for most clients people have been telling them what they should do and what they aren’t doing right forever. Which sometimes frustrated clients in not wanting to work on their issues. However when they research and see for themselves why they are behaving the way they do and what if anything can be done to correct their maladaptive thoughts and behaviors it’s just amazing the amount of change that can happen. I totally agree with your point that a strong therapeutic alliance will lead to positive treatment outcomes.

      Reply

    • Tayler Weathers
      Feb 03, 2021 @ 14:08:21

      Hi Beth! I totally see where you’re coming from. Every time we discuss the therapeutic relationship, I wonder if it is not exactly equal to the therapeutic alliance: I think a relationship is how people interact, where an alliance is “a bond or connection” that I see as goal-oriented. So, I feel like your emphasis on “working together to develop treatment goals and methods for meeting them” is important – as well as the element of doing the actual work! I don’t know if a therapeutic relationship is necessarily the act of “identify[ing] maladaptive behaviors and faulty cognitions” as you say, but I think it definitely lays the groundwork for doing so!

      Reply

  3. Pawel Zawistowski
    Feb 02, 2021 @ 15:30:56

    1.
    My understanding of the therapeutic relationship is that the clinician goal should be directed to establishing a therapeutic alliance with the client. By doing so both the therapist and the client are active participants throughout therapy. Unlike a psychoanalytic approach, CBT is a collaborative process. Psychoanalytic is mostly clinician driven. Contrarily, a Rogerian approach would be heavily client based with not much direction from the client. CBT approach is a balanced approach of exploring the client’s condition, providing empathetic and genuine therapy, as well as direction, and interpretation of assessment. CBT uses collaborative empiricism to back up its effectiveness and is research based and action-oriented therapy. It integrates, tests, assessments, and modifies client’s thoughts and behaviors with approaches such as cognitive restructuring. Nonspecific factors such as empathy, genuineness, and interpersonal skills such as expertness, trustworthiness, and attractiveness all contribute into the quality of care. CBT sets the expectations early on so that the therapeutic alliance can be established. It typically beings with higher therapist activity and low activity from the client. During the middle phase of therapy, the clinician will be a bit less involved and the client will be about equally involved as the clinician. During the late phase of therapy, the therapist’s activity will decline and client activity will continue to increase. However, both clinician and client continue to collaborate in order to make progress, set treatment goals, and make sure client is doing their part of following through with their goals.

    2.
    Session structure is important for effective CBT because we are working in a professional setting. Anything without structure has no direction and will quickly become disorganized. Most clients feel vulnerable coming to therapy and therefore want and need structure in their life. CBT provides the clients with that structure. Having structured therapy provides reliefs, hope, and comfort that the therapy is a professional process and will bring positive change in the client’s life. It also models the collaborative nature of CBT and provides direction for both the client and the clinician.

    Reply

    • Beth Martin
      Feb 03, 2021 @ 01:35:48

      Hi Pawel,

      I liked that you highlighted how vulnerable some clients feel prior to and during therapy! It makes sense that structure, and knowing what’s going to happen over the next hour or so, could really help with that. I think one of the biggest boons to structure is how much knowledge/information it can give a client, making them feel more in control of their health. If you have a client feeling more in control, I’d imagine they’re more willing to get involved and hands-on later on in the collaborative process too!

      Thanks for posting,
      Beth

      Reply

    • Althea Hermitt- Mcpherson
      Feb 03, 2021 @ 02:09:54

      Hi Pawel, Your explanation of the reason why session structure is important and on point. I like that you focused on having structure due to the professional nature of the job while also emphasizing that without structure there will only be chaos due to no clear direction. I totally agree that if the therapist has no idea where the session is going then the client will feel equally lost and may feel like the therapist doesn’t know what they are doing. I can only begin to imagine how vulnerable a client must feel going to a therapist. So if they build up to courage to come to therapy then our job is to keep them engaged and be present. As beginning therapists, we continue to try to inspire and provide hope.

      Reply

    • Tayler Weathers
      Feb 03, 2021 @ 14:12:37

      Hi Pawel! I think you’re exactly right that session structure has a lot to do with professionalism. It would be weird if a doctor came into an appointment and just didn’t touch on any of the relevant points (problems etc.), so why not for a therapist! Plus, I think that therapy structure is, to some extent, the product that is being provided. Obviously the goal is to help the client modify their problematic cognitions/behaviors, and so the actual work to do that is what is being paid for – and that work requires some scaffolding, some structure, to actually complete. It requires an appropriate amount of time spent on the relevant topics and an awareness of the end goal. I think giving the clients structure helps relieve their anxiety or stress about the process because it shows that it actually has an end goal, and that there are relatively clear steps to get there. I know when I first went to therapy, I just felt like I had a problem and no idea what to do about it. So it’s reassuring to have those steps laid out, and to feel a little progress each session – which structure ensures will happen, to some extent!

      Reply

  4. Tayler Weathers
    Feb 03, 2021 @ 14:05:41

    1) The therapeutic relationship in CBT has two elements: the actual interpersonal occurrences between the therapist and the client; and the “relationship.” To me, the interpersonal occurrences create the relationship: for example, using the Rogerian skills (empathy, unconditional positive regard and genuineness) allow the client to see the therapist as comfortable, someone who can be trusted and worked with. The point of the therapeutic relationship is to create a true therapeutic alliance, where the client and the therapist have identified and agreed upon goals to work on. Collaborative empiricism seems to be this combination of therapeutic relationship (the collaborative piece) and the CBT skills required (the empirical piece). Thus, collaborative empiricism becomes the establishment and use of the therapeutic relationship to help the client do the work of therapy, namely identifying and modifying maladaptive cognitions and behavior. In order to accomplish the goals of therapy, the therapeutic relationship and collaborative empiricism must be active, with both the therapist and client putting effort into the outcomes of therapy. This effort is not just doing the work of therapy (challenging cognitions and so on) but also maintaining that therapeutic relationship: being empathetic, genuine, seeing the client positively and nonjudgmentally, and recognizing any potential problems in oneself or the client.
    2) Session structure is important because it maintains the work of therapy. It would be really easy to just let the client talk, to not push them or work towards any goals. Sometimes talking is necessary, but session structure makes sure that there is still work being done: reviewing homework, problem-solving strategies, and giving feedback, among other things. I think the session structure is a lot like a lesson plan for teachers – you have to have some idea of what you want to do, but be aware that you are not a perfect teacher, and that there may be questions and challenges, interruptions and crises. But ultimately the work has to take some priority, so that the session is actually worth the money the client (or insurance) is paying for it. Without session structure, it would be hard to standardize (and thus follow empirical methods) therapy, as well as make sure it is effective – if each session was just unstructured, and didn’t keep the thread of goals and treatment, therapy might not actually be useful to the client. It would just be an hour of talking or avoiding the issue. So, I think session structure is essential, because without a game plan, how could you actually make a play? (Please excuse my mixed metaphors today)

    Reply

    • Anne Marie Marie Lemieux
      Feb 03, 2021 @ 17:11:12

      Thank you for your notes. I thought you brought up a good point about needing interpersonal skills in order to establish collaborative empiricism. I also thought your note about the importance of maintaining the relationship is key. It’s one I overlooked to mention. While it is so important to build the therapeutic alliance, it is just as important to maintain it. I think in metaphors so I appreciated your comments about sessions structure. I agree that it is important to identify and follow through with the goal of the sessions by creating objectives to accomplish. Otherwise, I could see how it could end up being a very expensive conversation without real change occurring.

      Reply

    • Michelle McClure
      Feb 03, 2021 @ 19:28:12

      Hi Taylor. I really like how you refer to the structure of a therapy session being like a lesson plan for teachers. I would agree that the concepts are very similar. A teacher’s lesson plan might actually change a little more then a typical session structure would but really just like a lesson plan includes certain sections that remain consistent, a CBT session also includes components that remain consistent. It would be very hard to have a CBT session without a check-in and an update, or a problem solving portion. I hope you have a good weekend, stay safe and well.

      Reply

    • bibi
      Feb 03, 2021 @ 19:52:39

      Hey tay,
      I liked that you emphasized the difference between the interpersonal relationship and the “relationship” in your answer. I felt like it really hit on the idea that both the counselor and client are people. I feel like sometimes you forget that in all the reading and lectures that the client is just a human being and you really emphasized the importance of those interpersonal skills in the therapeutic relationship in your answer.

      Reply

  5. Anne Marie Marie Lemieux
    Feb 03, 2021 @ 17:03:02

    The therapeutic relationship in CBT is essential in order to work collaboratively towards goals with clients. Collaborative empiricism is the alliance that is created through rapport. It is essential so that action can be taken to shift a client’s thoughts or behaviors. It is the sense of working together towards a common goal. A strong therapeutic relationship has been shown to produce better outcomes for clients. Which makes sense if you expect a client to open up to you with their thoughts and feelings, they first need to trust the therapist to disclose anything of significance . A therapist can build a therapeutic alliance by using nonspecific approaches such as Rogerian qualities; empathy, unconditional positive regard(warmth), and genuineness. Showing true nonjudgemental caring for a client through non-verbal and verbal communication and matching to client expressions is key. Avoiding assumptions while setting goals helps the accuracy of client needs. Validating feelings will allow clients to feel heard and accepted is another important component. However, the timing of this is important so that you don’t present as overzealous or so late that they question your investment. It is also important not to validate distorted thinking in an attempt to connect. Interpersonal skills such as being an expert (fake it, until you make it!), maintaining confidentiality to provide trustworthiness, and attractiveness/professionalism will put clients at ease that they are working with a professional. It is also essential to provide a space of hope and optimism.
    Creating a session structure is effective in CBT because it sets the stage for trustworthiness. If there is an agenda it helps the client know what to expect and shows reliability, when it is followed through on. However, things happen and come up within a session, it is important to be malleable and be able to shift set if necessary. However, setting a framework helps clients feel at ease and provides a rhythm of consistency.

    Reply

    • Connor Belland
      Feb 04, 2021 @ 19:45:10

      Hi Anne Marie, I really like your idea that the patient and clinician should be working towards a common goal together, and its important also that both parties constantly remind themselves exactly what the specific goals are so that they can stay on track. I also like the idea of being empathetic and especially non-judgmental in order to gain the trust of the client in order for them to really open up to the clinician and get to significant disclosures of information from the client.

      Reply

  6. Michelle McClure
    Feb 03, 2021 @ 19:17:24

    My knowledge combined with the readings in Beck and Volungis explains that CBT is an interactive, dynamic and collaborative process between the therapist and the client. In CBT both the therapist and the client are active participants throughout the therapeutic treatment process. A strong alliance is built between the therapist and the client as they work on mutual goals to benefit the client. This alliance, otherwise known as collaborative empiricism, takes the therapist expertise and knowledge and combines it with the information the client provides and the clients personal goals and all of this information is used to modify the clients thoughts and behaviors to lead to more desirable outcomes for the client. Building this alliance is a crucial step in the CBT process and it is the therapist responsibility to maintain this alliance throughout the treatment process and throughout the stages of the therapy session. The therapist does this by taking time before a session to review important information from the previous session, taking time to greet the client personally and check in with the client about their mood and important events since the last session. When problem-solving with a client the therapist collaboratively decides with the client on the appropriate behavioral/cognitive interventions to ensure that the interventions will meet the client’s needs and treatment goals. Before the session is over the therapist takes time to go over what was discussed and assign the client agreed upon homework and ask for feedback from the client on how the session went.
    The therapeutic session structure is very important in CBT. When therapy sessions are structured but not so structured that they offer little to no flexibility the client knows what to expect from the session going into the session and becomes comfortable with the routine. Session structure is also important for the therapist so that the therapist does not accidently forget an important part of the session and also so that the therapist makes efficient use of their time as they often have an hour or less for the session and that time goes by quickly. The structure of a session makes therapy sessions different from just a chat with a friend and ensures that therapeutic work is accomplished. Also the structure of the CBT sessions really introduces clients to CBT and provides guidance and increase the collaborative alliance that is so crucial to effective CBT. The therapist does this by including the client throughout the process from identifying the goals the client wants to work on, to asking the client for feedback on how to make the experience better for the client. The stages do not have to be followed step by step like in the readings but each therapist brings their own unique take when working with clients but still maintaining the important component s of a CBT session.

    Reply

    • Bibiana Cutilletta
      Feb 03, 2021 @ 19:50:50

      Hey Michelle, I like how you really addressed the way that structure of sessions can provide a form of psychoeducation. I know that Dr. V mentioned in his lecture that structured sessions introduce the client to CBT and help them understand exactly what is going on in the session. I like the way you emphasized that in your answer

      Reply

    • Lilly Brochu
      Feb 04, 2021 @ 09:17:56

      Hi Michelle,

      The structure of the therapy session is important in creating a routine as well as building expectations that the client anticipates each time they attend a session. You made a great point about there needing to be flexibility within the structure of the session. The structure should not be extremely rigid because the client and/or their situations may change, or tend to be unpredictable. However, it is important to have a plan in mind if such change does occur. Moreover, the structure provides a framework for the client (that they may not have) and assists them in how to cope and approach their problems through a CBT lens. Great post!

      Reply

  7. Bibiana Cutilletta
    Feb 03, 2021 @ 19:49:14

    1. The idea of the therapeutic relationship is that there is an active collaboration between the client and the therapist and active participation of both parties. The client is informed throughout the process about the treatment plan, case formulation, etc. and it is important that the client plays a very active role in forming the goals of therapy. Collaborative empiricism is the goal of identifying maladaptive cognitions and behaviors and determining what the validity and utility of those behaviors/thoughts are. Basically, the idea is to determine how accurate those claims are and how it benefits the individual (hint: they aren’t helpful). Collaborative empiricism is important to the therapeutic alliance because it really fosters the overall effectiveness of CBT. Its important that the client be involved in this process because these thoughts and behaviors belong to the client. The client needs to identify them. Additionally, as we discussed in automatic thoughts and core beliefs, these thoughts and behaviors might be relatively difficult to change. It is important that the client works on this process and understands why these thoughts/ behaviors are valid or why they might not be necessarily helpful for them. If all this information came directly from the therapist to the client, the client might not actually change their views and the whole purpose of therapy would be lost.
    2. Clients often come into therapy when they are distressed and vulnerable. As a result, it is important for the therapist to provide a certain level of structure to relieve the clients distress and demonstrate expertness on behalf of the therapist. Often clients come into therapy not exactly sold on the idea of being in therapy. It is important that the therapist convince the client that coming into therapy was a good idea in the first session. A consistent structure provides direction in the session and allows the client and therapist to collaborate with one another to tackle the most challenging and important problems. It also plays a role in the overall effectiveness of therapy. If an entire session is spent talking about the action plan instead of focusing on a very pressing problem in the client’s life, then the client might feel they are wasting their time, they might not see the therapy process as worth it, and you as a therapist aren’t providing the most effective therapy. The structure of each session allows time for all the major things that need to be addressed in a session including checking in with the client, reviewing the action plan, prioritizing problems to discuss in the session, reviewing the next action plan and providing feedback.

    Reply

    • Maya Lopez
      Feb 04, 2021 @ 21:22:12

      Hey Bibi,

      I loved that you mentioned how the client is “informed”. This is so important because the client cannot be an active participant if they are not informed of what their goals are or what they are working towards. Clients also may be confused about the efficacy of therapy without being informed of research-based approaches and interventions. I also liked your point of if all the information just came “at” the client that they may not truly change because they don’t know how, or why it would be worth it. It is so vital clients are informed throughout the process. I agree with your second answer, I mentioned in my response as well that the structure of sessions may be comforting to those who are already distressed and may appreciate having stable expectations of what will happen in a session. I also agree that the therapist must find a good balance and not talk too much about action plans and make sure they inquire about the distress the client is experiencing. The structure of the sessions does help with this and may convince new clients of the therapist’s expertise in their field enhancing the likelihood that clients will come back for another session and will continue with hope/ optimism that therapy will work.

      Reply

  8. Cassie Miller
    Feb 03, 2021 @ 20:33:39

    The therapeutic relationship is vital to one’s success as a therapist. The rapport that the therapist has with their client predicts the likelihood that they will continue therapy, share important information with them, and have positive outcomes. In order to develop this relationship the therapist should convey the Rogerian qualities of empathy, unconditional positive regard, and genuineness. These qualities help to portray the therapist as an understanding, authentic, and favorable individual who cares about the welfare of their client. The therapist should focus on their timing and non-verbal and verbal expressions when being empathetic. If they come on too strong or don’t use it enough the client can be left to feel uncomfortable and unsure about what the therapist is actually thinking. When using CBT, the therapist should always make sure to empathize with the emotion, but not to always empathize with maladaptive thoughts (as this may lead the client to believe that the therapist agrees with this negative belief). For example, if a clinician were to empathize with a clients thought of never being good enough, it may lead them to feel as though overcoming this barrier is not possible. In addition, the therapist should match their verbal responses and facial expressions to how the client feels, while avoiding assuming their emotions and responding prematurely. The better your relationship is with the client (based off of your empathetic responses) the more likely they are to provide the personal information that you will inevitably need to make real progress. A non-judgmental attitude is also very important and can be referred to as unconditional positive regard which allows the client to feel as though they can share embarrassing information with you. Lastly, genuineness can be brought forth through the therapist’s optimism for client change and can be enhanced by building upon a client’s weaknesses and emphasizing their strengths. The natural and sincere attitude of a genuine therapist will make all the difference for a client. To effectively do this the therapist must be self-aware in their responses, even if they feel triggered in the moment. They are there to validate feelings and not to judge them in an effort to change maladaptive thoughts so that they can exhibit real life change.

    Another vital part of the therapeutic relationship in CBT is collaborative empiricism which is action-oriented and embodies the therapeutic alliance, while also being backed by scientific evidence. Thus, the therapist is working together with the client using research-based approaches and tests that will modify their maladaptive thoughts and behaviors. Eventually, this approach should provide the client with the tools to become autonomous in implementing these strategies independently. In order to steer the client towards autonomy it is important to use session structure within your sessions. Session structure is important because it provides a direction and focus for the therapy and this organization draws the client closer to you as a therapist. It also allows you to be more efficient in therapy with your goals and interventions. The four stages that you should use to structure your therapy are: pre-session stage, early session stage, middle session stage, and late session stage. The first stage allows the clinician to prepare for their upcoming session by doing things like checking their notes and going over how they will conduct the session. The second stage is where they check in with the client, do a mood and symptom check, set an agenda for what they will be doing during the meeting, and review any past homework assignments they provided the client with. The third stage allows the clinician to review the clients problem with them, implement problem solving strategies, provide feedback, and summarize their thoughts on the issues presented. The final stage helps to bridge the gap for the next session and allows them to provide closure with the client and assign them with any new homework. The therapist should also ask the client how they felt about the session and if there is anything else they want to touch upon briefly. As one can observe, by structuring your session in such a manner it allows you to efficiently manage your time to fully address the client’s problems, while providing feedback and strategies for them to work on. These stages are especially helpful in keeping newer therapists organized and to guarantee that they are using the clients time to the best of their ability.

    Reply

    • Brianna Walls
      Feb 03, 2021 @ 23:19:35

      Hi Cassie! I really enjoyed reading your response. You really elaborated on the Rogerian qualities; empathy, unconditional positive regard, and genuineness. I agree with you when the therapist portrays themselves as understanding, authentic, and favorable, and they show the client that they truly care about their client, this will lead to a strong therapeutic relationship. Further, I like how you talked about how the therapist should never empathize thoughts but only emphasize emotions. I think this is extremely important because you as the therapist do not want your client to think that you might agree with their negative thoughts/ beliefs.

      Reply

  9. Lilly Brochu
    Feb 03, 2021 @ 22:06:18

    (1) From what I have gathered so far, the therapeutic relationship is an important aspect of the CBT process. For there to be effective therapeutic outcomes, there needs to be a strong “alliance” between the therapist and the client. Being in an “alliance” is far more than any “normal” or “typical” relationship. The difference is that within CBT, the relationship between both parties is mutually driven towards achieving specific goals and outcomes. This “collaborative empiricism”, or mutual process of working together, has been found to be the key factor that proves the effectiveness of CBT. The ways in which the therapist and client achieves these goals are through empirically supported assessment and intervention techniques. CBT focuses on change, and is driven by modifying clients’ maladaptive cognitions and behaviors. It is important to understand that within CBT, the therapeutic alliance is not the entire reason that allows for change, but it is essential for obtaining desired treatment outcomes and improvement of the mental health and overall well-being of the client. Moreover, it is important to note that there can be both positive and negative outcomes within the therapeutic alliances. For example, there are better outcomes for clients who build a strong therapeutic alliance with their therapist compared to those who do not have one. There are several qualities within a therapeutic alliance that may influence or sway the nature of the therapeutic relationship, such as non-specific and specific factors.

    Non-specific factors include several *obvious* characteristics of a good therapist: empathy, unconditional positive regard, genuineness, expertness, trustworthiness, and attractiveness. Empathy is extremely important in the therapeutic relationship, and it must be noted that what and how the therapist’s empathy is expressed is even more crucial. Additionally, unconditional positive regard is essential to being not only a good person, but a great therapist. Being warm, respectful, and accepting of your clients is important in building a solid and grounded therapeutic relationship. It is important that the clients coming for help do not feel judged, embarrassed, or ashamed for what they share in the therapy session. Also, the therapist must maintain genuineness towards their clients. It is important that they be honest and sincere with clients, but also be able to balance and understand the little monologue (thoughts, feelings) that is taking place in their own heads. This allows there to be constructive feedback from the therapist as well as a positive direction for the therapeutic relationship. As for expertness, it refers to the level of skills, knowledge, and expertise the therapist has in their field. If a client feels and knows that their therapist is able to help them, the more likely they will be more willing to participate and challenge themselves in sessions. Additionally, trustworthiness is a very important value that must be instilled on the surface to clients and within their practice – respecting clients’ confidentiality and following the rules and procedures of the practice are important in gaining complete trust from the client. Lastly, the therapist must be attractive, or rather, likeable and/or compatible in the ways they present themselves to their clients.

    As for specific factors, therapists must also note the therapist-client activity level, client specific factors, and conceptualization and treatment. Throughout the therapeutic relationship, there will be a change or fluctuation of activity level between the therapist and the client depending on the phase of therapy they are in (e.g., more therapist control during early phase, more client control during late phase). Next, the therapist must consider client-specific factors that may be present (e.g., life experiences, psychological distress, racial or ethnic backgrounds). Everyone is unique, and it is important to consider each client with flexibility and sensitivity. Finally, conceptualization and treatment is an important step of synthesizing all information gathered of the client’s strengths, and what they are doing to inhibit their progress in therapy. Prior to this, there must be a strong mutual and collaborative alliance in order for the client to understand, trust, and be willing to challenge themselves, and take a step towards their therapeutic goals.

    (2) If there is no structure, focus, or directionality within the therapy sessions, then the CBT skills will have little to no value or effect on the clients. Most clients want or need structure when they are new to therapy. There is a sense of comfort and relief that therapy might be helpful when they can see that there is structure and consistency within the therapeutic process. When there is structure, clients tend to view the therapist as more trustworthy and attractive. Moreover, consistency in the session structure can help clients to adjust to the practices of CBT, such as learning how to approach and solve problems on their own. Moreover, it can help the therapist to model the collaborative nature of CBT through being organized and having structure to do so. Overall, structure helps provide direction for both the therapist and the client. It helps to enhance therapeutic efficiency towards the therapist and client’s goals as well to conduct successful interventions. Furthermore, the amount of structure necessary for your clients depends on what stage of therapy the client is in. The early stages of therapy require more structure as the therapist to guide the client. However, compared to later phases of therapy, the client is doing most of the work while the client listens. One of my personal favorite parts of how CBT maintains structure is through the process of assigning homework. It helps to connect content and themes from previous sessions as well as a review for the therapist and client of what was discussed or worked on for the previous week. It also helps to organize, focus, and create a starting point picking up from where the session was left off.

    Reply

    • Brianna Walls
      Feb 03, 2021 @ 22:56:36

      Hi Lilly! I liked how you included the amount of structure needed based on what stage of therapy your client is in. I think it is important that during the early stages of therapy there needs to be a lot more structure than the later stages of therapy. I also thought it was important that you noted that during the later stages of therapy the client is doing most of the work while the therapist sits in listens, and gives their advice. Further, I like how you brought up homework. This too is something I like about CBT. It allows the client to go home and actually use the tools and advice given by the therapist on their own. Also, as you mentioned, it helps organize focus, and create a starting point for their next session. Thank you!

      Reply

    • Laura Wheeler
      Feb 04, 2021 @ 14:07:45

      Lilly, I really appreciated your response to prompt 2… I meant to talk about how different clients need different levels of structure depending on where they’re at in the therapeutic process and I forgot- I think its super important to emphasize that structure is one of the many things that is specific and different depending on each and every client. Further, I liked that you mentioned the change in engagement by the therapist and client as they work through the therapeutic process together; such as how towards the end of treatment the client is really doing more of the work while the therapist does more listening; I liked how the notes emphasized this in regards of role changes from teacher/student or mentor/mentee. I also thought you made a great point in mentioning that the impact of CBT is really dependent on structure to keep things on track and progressing in the right direction. Great job!

      Reply

  10. Connor Belland
    Feb 03, 2021 @ 22:22:50

    1. The Therapeutic relationship between the clinician and the client is crucial to effective therapy. We have talked previously about the importance of building rapport with each client because its important for them to trust the clinician in order for the client to fully open up too the clinician. Trust is also crucial for this clinical alliance because CBT works best if the client fully cooperates and contributes to the relationship. The clinician will be able to best help the client id the client is also trying to help themselves. The client needs to feel like they are a part of the process of therapy, the client needs to be able to learn to help themselves with the help of the clinician. This way when the client leaves therapy they wont be helpless and will hopefully have built up confidence in their own strategies to cope with whatever problems they are facing without the help of a therapist. Therapy shouldn’t consist of the clinician lecturing the client the whole session, it should be more of a give and take.
    2. Structure is important in a therapeutic session for a few reasons. For one thing it makes the clinician look like they know what they are doing, we learned how important perceived expertness for the client to trust the clinician. Structure in the session could reassure the client of this and help them build trust. It can help the clinician make sure that they hit all their important questions and goals as well, as goal setting can be important in therapy. A plan to try and touch on these goals is helpful and makes sure there is room to fit within any time restraints of the session. Of course, things happen and the structure isn’t always kept as maybe some things take longer to talk about then others, but that can help get to the root of the problems in some cases.

    Reply

    • Lilly Brochu
      Feb 04, 2021 @ 09:02:54

      Hi Connor,

      You have made several important points about the therapeutic relationship! It is crucial that there is a give and take between the therapist and the client rather than the therapist lecturing and dictating the direction of the session. When both the client and the therapist are working together towards a mutual goal, the client will eventually develop the skills and tools to be able to cope on their own without the help of the therapist. Furthermore, it is important to know and understand that life is unpredictable and we can never plan situations to go exactly as we had in our head. With that in mind, the way we structure things for our client initially may need further tweaking or modifying if the situation or individual changes in some way.

      Reply

    • Anna Lindgren
      Feb 04, 2021 @ 11:04:01

      Hi Connor,

      Great post! I think that the structure of the therapeutic session is helpful for both the client and the clinician, especially trainees like ourselves. Going into the practicum and internship experience knowing that there are specific structures for each session takes some of the pressure off of knowing what to ask or how to start each session.

      See you in class!
      Anna

      Reply

    • Zoe DiPinto
      Feb 05, 2021 @ 12:09:39

      Hey Connor!

      I’ve been thinking a lot about how the media portrays therapy. From TV and movies, I believe people create schemas around what they believe a therapy session should look like. Often, there is rapport between the clinician and client, but there is a clear status difference. The clinician will often say the magic words that create insight for the client. However, the “collaborative” nature of CBT emphasizes the importance of the client gaining insight on their own. I worry that many clients may be frustrated with therapists because they don’t have the “magic words” to solve their problems. Alternatively, I believe many people (especially modern american men) avoid therapy because they have an understanding that there are no magic words to solve a problem. And if a clinician cannot verbalize magic content to solve a problem, they must have all of the problem-solving skills they need within themselves. So therefore, what is the point of therapy if they will do all the work anyway?
      I want to find a comprehensive way to introduce and advertise what therapy really looks like that empowers individuals to collaborate with a clinician rather than a) expecting the therapist to do all the work or b) expecting the therapist to sit back and let you talk it out.

      Reply

  11. Brianna Walls
    Feb 03, 2021 @ 22:48:32

    1. The therapeutic relationship between the client and the therapist is extremely important. Research has shown that if there is a strong therapeutic relationship there will be a greater outcome in therapy. In CBT, the therapeutic relationship is seen as teamwork, the therapist and client work collaboratively towards mutual goals. Nonspecific factors are used during therapy across multiple different theories. Two of these factors are known as interpersonal skills and Rogerian qualities. A few interpersonal influence process factors that are important to integrate into the therapeutic alliance are known as expertness, trustworthiness, and attractiveness. These factors are known to greatly enhance the purposeful nature of collaborative empiricism in CBT, also including client engagement. Further, Rogerian qualities are equally important for effective CBT. They include empathy, unconditional positive regard, and genuineness. It is important for the therapist to set expectations early in CBT. For instance, in the beginning, stages of therapy the therapist will almost act as a teacher and the client will act as the student. As therapy progresses the therapist’s activity will slightly decrease and the client’s activity will start to increase. Towards the end of therapy, the client should be able to take home the therapists’ advice and tools that they had shared throughout their therapy sessions and apply them on their own.
    Collaborative empiricism is an action-oriented therapeutic alliance driven by research that integrates, tests, and modifies clients’ thoughts and behaviors. In other words, therapy is backed up with empirical research and is a collaborative based therapy. Although non-specific factors are important, collaborative empiricism is the key therapeutic alliance factor that fosters the overall empirical effectiveness of CBT. The primary focus of collaborative empiricism is to identify maladaptive cognitions and behaviors and then “test” for their validity and/or utility together. There are three key specific factors of collaborative empiricism; therapist-client activity level, client-specific factors, and conceptualization and treatment. I already discussed therapist-client activity level above, but it is important to note that unlike other theoretical orientations that have been historically one-directional, such as the psychodynamic model where the therapist is very directive, and the humanistic approach where the therapist is very non-directive, CBT is a balance between the two where the therapist and the client work together. Within client-specific factors, there are three factors that the therapist should consider when building a therapeutic relationship; the client’s presenting symptoms, environmental stressors, and sociocultural factors. Lastly, conceptualization and treatment is another key factor for CBT. It is important for the therapist to synthesize the client’s information into a working CBT conceptualization and then a corresponding treatment plan.
    2. It important to have a session structure for effective CBT for a number of reasons. For one, most clients want and need structure. Typically a clients will attend therapy because they are distressed, therefore, if there is a structure to the therapy sessions they attend this may help them feel less distressed and possibly make them picture a positive outcome from therapy. Further, the structure will provide direction for not only the client but for you as the therapist as well. It will further enhance the therapeutic efficiency by facilitating organized therapy and therefore the therapist and client will be focused on the most relevant problems and corresponding goals and interventions. Along with the therapeutic relationship, a sense of structure will also demonstrate your expertness, trustworthiness, and attractiveness as a therapist. Lastly, by having structure your therapy sessions can be broken down into four stages; the pre-session, early session, middle session, and late session. Once again, this will allow the therapist and the client to stay on track and have an effective session each visit.

    Reply

    • Anna Lindgren
      Feb 04, 2021 @ 10:24:32

      Hi Brianna,

      Thank you for this thorough response, it served as a great review of the content! I really enjoyed your description of how the level of client and therapist involvement shifts over the course of therapy. I’m beginning to look at it kind of like training wheels on a bike. At the beginning of therapy, the client needs lots of support and the therapist acts as the firmly secured training wheels, guiding the client’s progress through homework and interventions. With the help of the consistent therapeutic structure, the client starts to become more confident in their abilities to problem-solve and challenge automatic negatived thoughts, and the therapist can loosen the training wheels, so to speak, by prompting the client to come up with their own homework and set the agenda at the beginning of the session. In a perfect world, by the termination of therapy, the client feels fully confident that they can implement the coping strategies they’ve learned on their own and no longer feel as though they need the therapist. I completely agree with what you said about the clients needing structure in therapy. As someone with an educational background, I heard this about kids all the time, but I believe it’s true for anyone, especially individuals seeking help.

      Thanks for the post, see you in class!
      Anna

      Reply

    • Laura
      Feb 04, 2021 @ 14:01:14

      Brianna, I think you make a great point about clients wanting and needing the structure that is provided in CBT sessions (even though sometimes they probably think otherwise). I think you’re right in that ultimately if a client is coming to a session while dealing with a certain level of distress, having structure, predictability, and clear expectations would help to minimize their distress (similar to children, when I think about it) and hopefully have them leaving in a better space than when they arrived.

      Reply

  12. Yen Pham
    Feb 04, 2021 @ 02:25:02

    1. Understanding of the therapeutic relationship in CBT

    I understand that the therapeutic relationship is an integral aspect of CBT. The unique nature of the relationship within CBT includes the concepts of collaboration, empiricism and Socratic dialogue and their use across the various stages of therapy. The therapeutic relationship may be defined as an exchange between therapist and client with the goal of sharing intimate thoughts and emotions to facilitate change. In the context of CBT, therapists can utilize “common” relationship elements, such as expressed empathy or active listening that are similarly understood in a wide variety of therapeutic camps, or “specific” elements such as collaboration, empiricism, and Socratic dialogue that acquire a distinct meaning within CBT. Put in simple word, collaborative empiricism, which involves a systemic process of therapist and client working together to establish common goals in treatment. Clients and therapists become co-investigators in identifying goals for treatment, investigating patients’ thoughts about treatment goals, and predicting barriers. These strategies allow the client and therapist to jointly explore beliefs about challenges, discuss possible solutions, and ascertain what the client is willing to try. I believe an effective therapist understands that that a favorable first impression will greatly influence how the client responds in subsequent interactions. Many clients will not come to see the therapist again because of the poorly conducted in early therapeutic relationship. It has been shown that the client’s intake assessment sense of competence is enhanced if the therapist shows the ability to appreciate the client, to consider the extra-therapeutic issues related to effectiveness, to form an alliance, and to conceptualize counselling in productive ways. This is also known as the propagation of hope and involves confidence, patience and enthusiasm, all designed to model to clients the expectation for relief.

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

    CBT therapists use a particular session structure. It’s really a wonderful way to approach each session. I can I can explain why, first of all structure helps the therapist be more time efficient and helps the client begin to understand what they can expect from each session. Second, session structures provide the roles and requirements of the client and the counselor in the session, the sequences of the process, and events likely to occur as they work toward problem solution. Such structuring, whether explicit or implicit, gives evidence of the therapist’s expertness. Since the client perceive that the therapist knows what he is doing, explicit structuring may be more effective than implicit structuring. There is some evidence that explicit structuring does enhance counseling effectiveness. Structuring also enhances the therapist’s informational influence. The client is provided a rational framework to view his problem, the means of problem solution, and the importance of his efforts and further information. The therapist is thus more able to guide his clients toward problem solution as well as provide his client the best treatment. Put in simple word, following a set session structure, regardless of the presenting problem, helps maximize efficient use of time during therapy, and it also helps make the therapy process clearer for patients. It also helps to increase the efficiency of treatment, improve learning and focus therapeutic efforts on specific problems and potential solutions. I believe that each therapist has his or her own style, but be careful not to take advantage of structured sessions regardless of the client’s personality, emotions, and perception issues. If so, we are no longer psychologists, but technicians. Besides, when using structured sessions, depending on the circumstances and personality of the client, therapists should harmonize between phases, not necessarily in order.

    Reply

    • Elizabeth Baker
      Feb 06, 2021 @ 19:07:33

      Hello Yen!

      I really liked your explanation of why the therapeutic alliance is important. I especially liked how you said both the client and therapist are co-investigators in creating treatment goals and potential barriers for the client. Along with presenting yourself as an empathetic, expert, professional, and trustworthy therapist; it is so important to let clients know that therapy is a collaborative process, that it is not just the therapist educating and directing the client on what to do. The collaborative process is the most important factor to a beneficial therapy session(s)! I also like how you stated to not take advantage of the structured session, and to be flexible as clients come with their own agendas or may want to alter the structure of sessions.
      Additionally, your entire post helps me understand how to write my future posts, so thank you for allowing me to view your post as a guide!

      Reply

  13. Cailee Norton
    Feb 04, 2021 @ 12:56:39

    1. The way I look at the therapeutic relationship in a CBT setting is that we as therapists are there to educate, facilitate, and encourage the exploration of our clients thoughts, emotions, and behaviors. In order for this to be done however, we require that our clients are active participants in our sessions. This entails the therapists don’t sit and lecture about what a client should be doing and it also doesn’t entail the client sitting and talking aimlessly about their week with no guidance or challenging. The reason why CBT is proven to work for our clients is because it is a joint effort of both the client and the therapist in making changes to improve the quality of life our clients experience. Collaborative empiricism is focused on action and is backed by research that “integrates, tests, and modifies clients’ thoughts and behaviors” (Volungis, 2019). The reason that we can elicit change in our clients however is a direct result of the therapeutic relationship we hold with them. If our therapeutic relationship/alliance is weak, our clients won’t feel that they are supported enough to make the changes, their maladaptive thoughts and behaviors will take over and the therapists guidance will be of little value or input. By showing our clients empathy, non-judgement, and validation of their emotions we are able to build a foundation for future progress and success with therapy.

    2. It is vital for a session to have structure in order for there to be progress. Without structure you could miss important features of a client (like specific negative emotions that occurred in the last week), or you could forget to check in with the homework you assigned (which could negatively impact your therapeutic relationship and jeopardize your trustworthiness to your client). With a structured session, as therapists we are then able to know where to start and where to finish. As beginning therapists this seems a bit overwhelming and such structure seems impossible to appear authentic or empathic. Rather the opposite as it allows for your focus to be on the material of the sessions rather than where the session should go. By having such structure therapists are equipped to efficiently make progress towards treatment goals and enacting interventions discussed during sessions through collaborative efforts. Such structure also adds to a therapists expertness, trustworthiness, and attractiveness as professionals, adding to the therapeutic alliance.

    Reply

    • Maya Lopez
      Feb 04, 2021 @ 21:13:24

      Hey Cailee,

      I liked your emphasis on how the client is exploring and we are mere facilitators of the exploration via education and encouragement. I think “facilitate” was the perfect word to describe therapists. Many people may assume that we are here to give advice about how clients should change and live their lives however it is not this direct; and your right that clients must be active in their own healing process. I can see why some may think CBT is cold and calculated by the way collaborative empiricism is defined but in real life, I think it is just a more scientific approach to the therapeutic relationship. I also liked that you mentioned what would happen without a structured session. It could be easy to get sidetracked especially by a client who may be resistant to discussing a certain topic. I agree with you that as a beginning therapist it seems like a lot to be thinking about during a 50 min session like oh now I spent too long in the late stage and not enough time in the middle stage. But after we get used to it I’m sure it will be for the better to keep therapists and clients on track and organized. It gives therapy more of a similar approach to what I assume PT would be like. Although I never have had to go, I would assume physical therapists have a plan of what exercises to do that day and change their routine depending on the client’s abilities that day and what is more or less sore. They don’t have clients come in and just make up on the spot what to work on, they have goals of what they want their clients to reach and think of exercises and strategies of how to get them there while the client does the hard work of the exercises themselves.

      Reply

    • Zoe DiPinto
      Feb 05, 2021 @ 11:44:00

      Hi Cailee,

      I like your point about session structure being a facilitative tool to gain perspective in what has happened since you last saw the client and learn about their current emotions. I’ve been thinking a lot about how CBT emphasizes the present moment rather than diving into past experiences. However, I believe it may be difficult for a clinician to draw the line between wanting to focus on the immediate experience vs the overall goal. Hopefully, these two areas of focus will intercept enough to both improve with treatment. But when they are unrelated, when should we decide to pause treatment on the overall goal to focus on the present moment or vise versa?

      Reply

  14. Elizabeth Baker
    Feb 04, 2021 @ 13:04:13

    1) The therapeutic relationship is one of the most important aspects of therapy; as clinicians, we must create a space that is welcoming, empathetic, and nonjudgemental to ensure that our clients feel comfortable and encouraged to cooperate throughout the session, as well as future sessions. We also must show that we are experts and can be trusted that we will use our skills as efficiently as possible to produce the most beneficial therapeutic experience. As many of us have learned last semester in PSY 508, establishing rapport with our clients is most important on their first day of therapy, as this is the session that confirms or disconfirms their expectations of therapy overall. Therapy does not progress with just the help of the therapist, the client needs to do a lot of internal and external work on their end as well. Therapy is a collaborative experience where both the therapist and client work hard to create and reach goals for the client. The therapist has the job of applying their knowledge and skills while remaining empathetic and nonjudgmental, while the client has the job of cooperating during sessions and using their learned coping and adaptive skills between sessions. I think it is important to note here that not all clients are happy to be in therapy, they may have been involuntarily referred to therapy or they may feel anger towards authority figures, so it is especially important to establish an alliance with these clients. In addition to building an alliance, this alliance comes in stages, and the therapist-client session participation fluctuates as they progress through the stages. There are three stages: the early, middle, and late phases. The early phase is when the therapist spends more of the session time educating clients on the concepts of CBT and how it is going to be helpful during the therapeutic experience; the middle phase encourages a more balanced client-therapist participation during the session as they come up with treatment goals; and the late stage encourages the client to be more active during the session as they discuss their current positive outcomes and ideals from their therapeutic experience. Without having a secure alliance with clients during the beginning of therapy, there is no guarantee that the client will be as collaborative as therapy continues.
    2) Although therapy may seem as if it is “going with the flow,” there is structure behind the theory of therapy. Firstly, therapy is an evolving process, the client and therapist are continuously working off each other to ensure the client is gaining and improving to reach their ideal versions of themselves. Additionally, therapy is goal-oriented, and there needs to be structure in order to help clients create and reach those goals. As we know, goals are not achieved miraculously; there are steps between the present and future goals, and we structure and organize our lives to reach these goals. It is important to have structure in therapy because it creates a sense of organization as both the client and therapist understand what will be focused on during each session. If there is not structure, therapy may not run as smoothly as the client and therapist will go back in forth trying to prioritize what to focus on during the session. Moreover, the client may feel that the session is disorganized or ineffective if there is no sense of structure. More importantly, some clients need structure in their lives, as they feel out of control and anxious if they do not have a sense of organization. That being said, not only is having structured sessions helpful for the therapist, but it is also helpful for the client as they can highlight what they feel needs to be altered or prioritized during future sessions. Doing so will help the collaborative process as the therapist and client communicate and learn from their constructive feedback.

    Reply

  15. Laura Wheeler
    Feb 04, 2021 @ 13:55:32

    (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?
    My understanding of the therapeutic relationship in CBT is that it is commonly referred to as an alliance, which is defined as a relationship where people work together to achieve mutual goals, in CBT this means that both the client and therapist are active participants in the therapeutic process. The idea of collaborative empiricism is defined as a therapeutic alliance driven by research that integrates, tests, and modifies clients’ thoughts and behaviors.

    A therapeutic relationship is exceptionally important in CBT because research consistently shows that a strong rapport between the therapist and client impacts treatment outcomes. A strong therapeutic relationship is important in all theoretical approaches, but a positive relationship in CBT is said to be a strong predictor of symptom improvement, solidifying its significance in therapeutic relationships.

    Some of the general, “non specific” factors that are important in building a positive therapeutic alliance are empathy, unconditional positive regard, and genuineness; each of which are important in all therapeutic approaches but can be tailored to be most effective with the use of CBT. Expertness, trustworthiness, and attractiveness can be especially impactful in collaborative empiricism. In collaborative empiricism the goal is to identify maladaptive cognitions and behaviors and then “test” if they have any validity or utility. In order to complete this process with success and honesty, it is important that the client feels they can share openly with their therapist without judgement. Trustworthiness is especially important in terms of clients feeling comfortable sharing their personal and more vulnerable information. It is also important that clients feel as though their therapist is an expert, this helps to feel confident and invested in the process; something that helps with this is setting expectations early so that the client knows that there is a plan and that the therapist knows what they’re doing. Setting expectations early on in the therapeutic process also helps to establish a “team effort” that includes both therapist and client activity- which is a critical part of collaborative empiricism. Further, the more clients agree with their CBT case formulation, treatment goals, and interventions, the more likely they are to have success; which all relates back to the client feeling that the therapist is a trustworthy expert, capable of formulating their treatment. In addition to “non-specific” factors, there are client-specific factors in CBT that are related to collaborative empiricism: presenting symptoms, environmental stressors, and sociocultural factors.

    As for CBT session structure, it is once again important to note that the very first session with clients is an important time to set expectations and explain what future session structure will look like. Having structured sessions has many benefits including introducing your client to the practice of CBT, allowing for organized and efficient sessions, and keeping the process on track and moving in a productive direction. CBT session structure includes four parts: pre-session, early session, middle session, and late session. Pre-session includes a review of client information, which is likely brief. Early session including checking in with the client, asking open ended questions to get a feel for your clients symptoms and mood, setting an agenda for the session, and reviewing homework from the previous session. Early session is important because it allows the therapist to get an idea of what work the client has done during the week and where they are currently at, which allows for an assessment of overall progress. Middle session includes a focusing on a specific agenda item and coming up with a collaborative and appropriate plan to address it. Late session includes summarizing the session, assigning homework, and allowing the client to ask questions and provide feedback.

    Reply

    • Lina Boothby-Zapata
      Feb 06, 2021 @ 15:06:13

      Hi Laura,

      Thanks for bringing in these ideas related to the Therapeutic Alliance / Collaborative Empiricism-Specific Factors. Last class PSY 600 Dr. V referred to therapeutic alliance as a building rapport or the matching two and introduced us with the part of no-specifics referring to Strong and his three factors, effectiveness, trustworthiness, and attractiveness. He also said in different occasions that therapist should meet at the client’s level. I explained this because I currently work with youths. If something is clear for me, an oppositional behavior can’t have an oppositional defiant answer because the youth’s response will be “I will run away”. For this class I perceived a more elaborate proposal for the Therapeutic Relation in CBT. Dr. V introduces in the Table 2.2 the client’s challenges and the possible considerations to response in the therapeutic relationship. For example; if the client is having low motivation or hope, the therapist should increase validation, affirmative statements, and reflection of feelings. At least for Depression, Bipolar, Substance abuse, Borderline personality or anger, the therapists need to be flexible enough to respond in a particular way to these challenges. The therapist should receive these recommendations to strengthen the therapeutic relationship.

      Reply

  16. Anna Lindgren
    Feb 04, 2021 @ 13:59:23

    1. The therapeutic relationship is a key component to successful cognitive behavior therapy. A strong therapeutic alliance has shown to have more positive therapeutic outcomes for clients, so building rapport should be a key goal for any therapist practicing CBT. Some nonspecific factors that are used in most therapeutic approaches are expressing empathy, treating the client with unconditional positive regard, and conveying genuineness, expertness, trustworthiness, and attractiveness to the client. All of these components help the client to feel more comfortable opening up to the therapist, which will ensure a greater understanding of the client and therefore a more effective case conceptualization and treatment plan. Specific to CBT, collaborative empiricism refers to the combination of collaborating with the client throughout treatment and the consistent use of empirically supported methods in an action-oriented therapeutic alliance. This approach works because it is both grounded in well-researched CBT skills and tailored to the client’s individual needs.

    2. Session structure makes the therapeutic process easier and more effective for both client and clinician. It provides a consistent framework for the client to learn over time so that they can become more actively involved in setting the agenda, suggesting interventions, providing feedback, and assigning their own homework that they think will help them best. Therapy evolves over the course of sessions and begins with the therapist providing psychoeducation and orienting the client to CBT and aims to end with the client feeling empowered in being able to utilize the CBT skills themselves to maintain the positive progress they’ve made during therapy. Session structure is also helpful for the clinician to plan what topics will be discussed and what interventions would be appropriate from one session to the next. While it is important to have a general plan before meeting with the client, therapists should also be flexible to adapt to what the client needs in that session. Without session structure, the clinician may use CBT skills, but they will not be as effective because there is not a sense of progress from one session to the next.

    Reply

    • Elizabeth Baker
      Feb 06, 2021 @ 18:52:22

      Hello Anna!

      I enjoyed reading your post, great job on summarizing the contents for this discussion! Both the therapeutic alliance and session structure are so very important to the outcome of therapy. Although I am sure it may be difficult at times to follow session structure, since what you may have planned may not work or run as smoothly with all of your clients. Clients may come with their own agenda of what they want to talk about, which may drift from what you as a therapist have planned, and other clients may simply not want to cooperate during therapy. Although there are strategies to go about session structure, I wonder what techniques are out there on how to alter your sessions for those clients who do not want or are apprehensive about therapy.

      Reply

  17. Zoe DiPinto
    Feb 04, 2021 @ 14:03:58

    The therapeutic relationship in CBT guides many interactions and is therefore very important. Collaborative empiricism is a term used to describe the mutual action-based relationship between the therapist and client. Establishing a rapport will be different for every individual, but there are non-specific factors that guide many therapist-client interactions. These factors include empathy, unconditional positive regard, genuineness, matching verbal and non-verbal responses, and avoiding assumptions in the client’s experience. These factors often come naturally to people pursuing a career in psychology. As well as these nonspecific factors, there are also CBT specific factors that will strengthen the functions of collaborative empiricism. CBT emphasizes the collaborative nature of the therapy process. The client should not have a passive role in sessions. The activity level of client and clinician will fluctuate depending on the phase of therapy. In addition to this collaboration, there is ample opportunity to build rapport. In a CBT context, it is important to validate client emotions to build a relationship. However, clinicians should be cautious of validating thoughts, as they can often be maladaptive and driving problematic behavior.

    It is important to provide structure to sessions. Having a structure to a session will be able to create a sense of consistency within the client and clinician. The clinician will maintain focus, while both parties will have a clear understanding of the direction of therapy. Having focus and direction will increase the likelihood that the individuals involved will feel linear progress as they proceed. This will also increase efficiency and will socialize the client to the structure of cognitive behavioral therapy.

    Reply

    • Lina Boothby-Zapata
      Feb 04, 2021 @ 14:19:39

      1. Therapeutic relationship in CBT (include collaborative empiricism in your discussion)?

      The therapeutic relationship is the relation installed by the counselor and the client and it is activated when the therapist made contact with the client, this includes the first phone call. In CBT the therapeutic relationship has specifics characteristics that differentiate it from other psychology theories. CBT therapeutic alliance is characterized by active and mutual participation of therapist and client in the process. They both work together toward a mutual treatment goals plan. A second characteristic is a Collaborative Empiricism. This means, that the therapist’s actions are driven by “research that integrates, tests, and modifies client’s thoughts and behaviors”. Research has proved that disregard the theoretical approaches in psychotherapy, there is a strong connection between the therapeutic relationship and the outcome of the treatment and it can have a positive or negative impact on the client’s well-being. Furthermore, if we get experts in the clinical field the therapeutic alliance can be a great instrument to create positive behavioral changes in the client.

      Dr. V brings into the therapeutic relationship two factors. Nonspecific factors and CBT – specific factors. Nonspecific factors are composed of elements; Rogerian qualities and interpersonal skills. Rogerian qualities; empathy; is the capacity of the therapist to look through the client’s lenses and really make the effort to understand the client’s thoughts, emotions, and behaviors. It is important to clarify that empathy is not pity. Unconditional regard is the capacity of accepting the client’s situations and behaviors without judgment even though if the client is touching the therapist’s own values and bias. Genuineness is presenting to the client a natural, honest, and sincere manner. A second nonspecific factor is Strong’s Interpersonal Skills; expertness in the counseling field means, first the professional ambient that the counselors are providing to their offices. Second, the counselor’s behavior and performance of expertise translate into the counselors’ ability to perform a structured and clear interview to the client. Third, trustworthiness is the counselor’s capacity to focus the attention on the client’s statements and behaviors, communicating the concerns related to the client’s wellbeing, avoiding questions that made intentionally by curiosity, and assuring confidentiality. Strong (1668) located these factors; expertness, trustworthiness, and attractiveness in the “interpersonal influence process” or modern terms building rapport with a client. This is what Strong has named the Two-Phase Model of Counseling or (to remind measurement class) the Matching Two. If the counselor can control and enhance these factors’ utility, the counselor will promote behavioral change and accomplish therapy’s goals.

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

      J. Beck recommended for the first session, divide the session into three stages. The initial part where the therapist set the agenda, do a mood check, obtain and update the client, and discuss the client’s diagnosis and do psychoeducation. In the middle part of the first therapy session the therapist has a goal; identify goals and problems with the client and set goals, educate the client about the cognitive model, and discuss the problem. The end of the session is provided or elicit summary, and review homework assignment and elicit feedback. Will allow the therapist to have a work agenda that can allow the therapy to advance, progress, and assess throughout the sessions. J. Beck stated that an experienced CBT therapist needs to accomplish so many tasks at once; such as conceptualizing the case, building rapport, socializing, and educating the client, identifying problems collecting data, testing hypotheses, and summarizing. J. Beck recommended for the new therapist to don’t look at the whole picture in CBT because there is a lot in the scenario during the sessions, and there is also a lot of techniques and homework which to decide to apply to the client. Her suggestions are to take the opportunity of the structured interviews that the CBT model offers and concentrate on fewer elements during the session. J. Beck recommended that the first thing to learn in the structured interviews is to learn the skills of developing the therapeutic relationship, the skills of conceptualization, and the techniques of cognitive behavior therapy, everything is learned in a step-by-step manner.

      In sum, I understand the Structure interview as the roadmap to let the client know what is the content of the session and what we are going to work on during the session. At the same time will demystify the anxious question about what are we going to do today in the session. On the other hand, it provides the therapist with the opportunity to complete his agenda and touches all the important points that made part of a session.

      Reply

      • Yen Pham
        Feb 05, 2021 @ 19:55:52

        Hi Lina,
        I have enjoyed to reading your post. You were bring in your answers of understanding and helpful details. I appreciate your answer on the relationship between therapist and client. It is essential and important for every encounter, especially in therapy. I agree with you that nonspecific factors and specific factors are two essential factors that is foundation of the therapeutic relationship in CBT. Like you, I regards to the terms trustworthy, expert and attractive are necessary to establish rapport with a client. First, trustworthiness is gained by respecting the clients’ confidentiality and following policies and procedures. I think that the therapist is trustworthy, that he has no selfish or devious motives as well as he assures the client that any information the client may divulge or that he may obtain is completely confidential. Expertness refers to conduct himself as confident in theory and practice. I think that the therapist’s confidence in his therapeutic theory and procedure enhances his counseling effectiveness. Such confidence enhances the client’s perception of the therapist’s expertise. Finally, I understand that attractiveness counselor is likeability and compatibility that comes from how he conducts himself during client interactions, NOT his physical attractiveness. In the first section, be attractive is directly related to the therapist’s unconditional positive warmth for the client engendered by the therapist’s empathy and therapeutic understanding. The therapist must be sensitive to the client’s feelings and the verbal facility to communicate this understanding in a language attuned to the client’s current feelings.

        Reply

    • Cassie Miller
      Feb 05, 2021 @ 18:09:53

      Hi Zoe,

      I really enjoyed your response, especially when you discussed therapeutic rapport looking different for each client. It is important to remember that some clients will respond positively to a more casual approach, while others will not. This is why focusing on their verbal and non-verbal cues is so important because this can impact the likelihood that they will return for another therapy session. I also liked how you mentioned that we cannot assume a client’s experience but instead must ask them specifically how it felt for them. If we assume the effect of the clients experience prematurely and our assumption doesn’t match with theirs it may leave the client feeling uncomfortable or like their feelings were “wrong.” This is why as clinicians we should explore the client’s thoughts and feelings first before providing feedback. In CBT the therapist’s job is to acknowledge the feelings (even if they do not understand them in the beginning), but work towards changing the maladaptive thoughts; the thoughts are what drive these feelings even if the client is not consciously aware of them.

      Reply

    • Cassie Miller
      Feb 05, 2021 @ 18:12:41

      Hi Zoe,

      I really enjoyed your response, especially when you discussed therapeutic rapport looking different for each client. It is important to remember that some clients will respond positively to a more casual approach, while others will not. This is why focusing on their verbal and non-verbal cues is so important because this can impact the likelihood that they will return for another therapy session. I also liked how you mentioned that we cannot assume a client’s experience but instead must ask them specifically how it felt for them. If we assume the effect of the clients experience prematurely and our assumption doesn’t match with theirs it may leave the client feeling uncomfortable or like their feelings were “wrong.” This is why as clinicians we should explore the client’s thoughts and feelings first before providing feedback. In CBT the therapist’s job is to acknowledge the feelings (even if they do not understand them in the beginning), but work towards changing the maladaptive thoughts; the thoughts are what drive these feelings even if the client is not consciously aware of them.

      For some reason this posted in the wrong area, even though I replied to Zoe’s specific post, so don’t worry if you see this twice!

      Reply

  18. Carly Moris
    Feb 04, 2021 @ 14:37:29

    1.
    My understanding is that the therapeutic relationship is extremely important for CBT. You need a strong client-therapist relationship in order to achieve effective treatment outcomes. This relationship is important from the start of therapy because early therapeutic relationships have been shown to effect treatment outcomes. There are factors that are specific and not specific to CBT that can effect the therapeutic relationship. Nonspecific factors include Rogerian qualities like empathy, unconditional positive regard, and genuineness. These factors help a client feel comfortable in therapy and that they can open up and trust the therapist with their problems. It is important that clients feel like they will not be judge and that the therapist understands them. While, Rogerian qualities are essential to therapy, alone they are not able to produce long-term help for clients. Other nonspecific factors that can effect the therapeutic relationship are trustworthiness, expertness, and attractiveness. If a client does not see the therapist as someone they can trust, as a competent professional who can help them, or as someone they can get along with, therapy will not be effective. There are also factors of the therapeutic relationship that are specific to CBT. Collaborative empiricism is a key factor in the therapeutic alliance for CBT. Collaborative empiricism is an action oriented therapeutic alliance driven by research that integrates, tests, and modifies clients thoughts and behaviors. The main goal of collaborative empiricism is to identify maladaptive cognitions and beliefs and the “test” their validity and utility. This testing of maladaptive thoughts or behaviors is not done by the therapist alone. A key feature of this relationship is that the therapist and client have a shared responsibility in client change. Therapists work with clients to identify problems, set goals, and work on interventions. As the name states collaborative empiricism is a collaborative process between therapist and client. This is a unique feature of CBT because other therapeutic processes are not as collaborative. There are three important aspects to collaborative empiricism therapist-client activity level, client specific factors, and conceptualization and treatment. As stated previously CBT is a collaborative process between therapist and client, however the therapist-client activity level will vary throughout the course of treatment. In early phases of therapy the therapist will have a relatively higher activity level compared to the client. During early phases of therapy clients typically need more guidance as they learn the structure and concepts of CBT, though they are still expected to be actively engaged n the process. In this phase of therapy the therapist client relationship resembles more of a student teacher relationship. In the middle phase of therapy the therapists activity level may slightly decrease, but the client’s activity level should significantly increase to be equitable with the therapists level. In this phase the therapeutic relationship should be highly collaborative. The therapist is still guiding the therapeutic process, but they are responding to feedback from the client, as the client is actively involved in in their own changes and improvement. In late phase therapy they therapist activity levels should continue to decrease, while the clients continue to increase. The client should be more autonomous in the therapeutic skills they have learned, to the point that when therapy is ended they feel comfortable using these skills themselves. At this point the therapist-client relationship should resemble more of a mentor-protégée relationship. It is also important to be aware of client specific factor in collaborative empiricism, because these factors can effect the therapeutic relationship. Client specific factors include presenting symptoms, environmental stressors, and sociocultural factors. It is important to be aware of and address these factors if need in order to establish and maintain a strong therapeutic relationship. Finally collaborative empiricism is important for good case formulation and treatment. It is important to work with the client during this process because only the client is an expert of their own experiences. This can involves sharing the case formulation with the client and asking them how accurate they think this is. While this part of the process can help build the therapeutic relationship, it also requires a strong therapeutic relationship because this is a sensitive process and can cause the client distress. Overall it is important for the client to know their diagnosis, the goals of treatment, and why certain interventions are being used. Due to the collaborative nature of the therapeutic relationship of CBT and the ultimate goal of helping the client gain the skills to become their own therapist we don’t want to keep this information from clients. The therapeutic relationship should involve sharing all relevant info with clients and answering any questions they may have. Which, should also help strengthen the therapeutic relationship.

    2.
    Session structure is extremely important for effective therapy. First of all session structure is a great way to display expertness which can help the therapeutic relationship. Consistent session structure also helps to familiarize clients with the structure of CBT and allows you to model the collaborative nature of CBT. But most importantly session structure helps you to stay organized and be efficient which increases the overall effectiveness of therapy. This is especially important in managed care settings, when you have a limited number of sessions with the client. Once you have worked with the client to establish and prioritize a list of problems, session structure helps you stay focused on the most relevant problems and their corresponding goals and interventions. Session structure becomes the driving force for the direction of therapy, and helps to ensure that the clients most important problems are addressed. In addition to staying on track, breaking down sessions into different sections with distinct goals or points to cover can also keep you from overlooking or forgetting to incorporate something into the session.

    Reply

  19. Maya Lopez
    Feb 04, 2021 @ 15:02:45

    (1) What is your understanding of the therapeutic relationship in CBT (include collaborative empiricism in your discussion)?
    As should be with any theoretical orientation, the therapeutic alliance must be established for effective therapy. It is one of the largest factors to predict the outcome, therefore is very important to CBT. The alliance is made to help the client feel comfortable enough to discuss vulnerable issues and it cannot be done if they think the therapist will be rude and judgemental. The alliance also signifies that therapy work is done on both sides collaboratively. Through collaborative empiricism and a strong alliance, both therapist and client can uncover specific goals to work towards which may improve motivation. Without a strong relationship, little structure, and no collaborative empiricism therapy would not be effective. Essentially it may just be talking to a really good listener. However therapists are more than this and their expertise and skills are shown in how well they can understand clients and work with them so they can live happier, healthier lives on their own.
    (2) Why is it important to have a session structure for effective CBT?
    It is important to have a session structure because it is helpful to clients to conceptualize what to expect and what is to come. Especially in anxious clients or those who have comorbid anxiety, it will be helpful to have a structure to therapy and not just come in, unknowing what could happen in a session. The structure can bring a bit of stability and homework can allow clients to feel like they are an active participant. It is also important for the therapist to have structure so that they can build objectives and goals to reach within each stage. Therapists should have an idea of what they want to accomplish each session and stage so that they don’t get distracted from the issues at hand and can effectively use their time to discuss those issues.

    Reply

    • Abby Robinson
      Feb 04, 2021 @ 17:56:55

      Hi Maya,
      I liked how in your description of why structure is important-you mentioned being efficient with the time clients have with their therapist. I didn’t think about this until reading your post, but since the client only gets a small chunk of time with their therapist every week (usually), there should be structure to help map out what the important aspects are of the session. Using the small amount of time each week wisely will help the client with goals and interventions. I also think it’s important that the structure can help the client create expectations when coming to therapy which will help them achieve their goals as well!
      See you in class!

      Reply

  20. Christina DeMalia
    Feb 04, 2021 @ 15:20:41

    1.
    Having a strong therapeutic relationship is an extremely important element of CBT for a number of reasons. Research shows that a strong relationship between the client and therapist are related to better treatment outcomes. One of the most obvious reasons for this is that if a client does not fit well with the therapist and does not believe they are a good match, they might terminate therapy completely. Even if the client remains in treatment, it is likely to be less productive and efficient. As our readings pointed out, efficiency in CBT is important for multiple reasons. If a client is suffering from symptoms of mental illness, it is obviously better to relieve those symptoms as soon as possible with an efficient system, rather than having the progress move slowly over many weeks. The sooner a depressed patient experiences a lessening of symptoms, the sooner their risk for things like suicide decreases. Another reason that efficiency is so important is because not all therapy can go on indefinitely, nor should it. In many cases, the number of therapy sessions covered by insurance may be limited, and therefore it is important to make the most of the limited time the client has in therapy.

    The reason a strong therapeutic relationship is important to the treatments efficiency and success is similar to the reason any partnership works better when the two people get along. Whether it is a school project, working with a co-worker, or even being in a marriage, fit between the two people involved makes a huge difference in the outcomes. If forced to work together, there is a chance two people who get things done could accomplish the bare minimum of the task. However, when two people respect each other, share ideas, work collaboratively, and feel they receive something positive out of interactions, they are far more likely to be successful and want to continue that partnership. In terms of therapy and CBT, the therapist’s job is to make sure they are a good fit for the client, no matter who the client is. By knowing the client, the therapist can match their tone and attitude to that of the client to portray a good fit and attractiveness to the client. The therapist should show empathy, unconditional positive regard, and geniuses to build the trust of the client. They should also demonstrate expertness trustworthiness and attractiveness in order to further improve the client-therapist relationship.

    The reason why this partnership is particularly important in CBT is because much of the therapeutic process is based around collaborative empiricism. CBT is based around the idea that both the therapist and the client are active participants in the therapeutic process. This means that action must be taken by the therapeutic alliance working together. The responsibility in change is shared by both the therapist and the client. The focus on collaborative empiricism is to identify maladaptive thoughts and behaviors and then test them for their empirical validity or utility. Through this process, clients are able to have more adaptive cognitions and behaviors over time. Although collaboration between the therapist and client remains important throughout the process, the roles do slightly shift throughout the treatment period. In the beginning the client may need more guidance from the therapist while elements of CBT are being taught. Towards the middle and end of the time together, the client learns and develops more CBT skills and is able to take more of a leadership role while the therapists role can decline to more of a supportive one. Even then, both members in the therapeutic alliance have important jobs and must actively participate in treatment.

    2.
    This is a topic that I touched on in my response to last week’s discussion questions. Structure is something that can be beneficial in many ways, even though some other forms of therapy may not have such a set structure. As I mentioned previously, efficiency in therapy is important, so having an organized structure to each meeting can keep the process moving quickly and in the right direction. For many people, they are coming to therapy because their life is disordered or complicated. Not only that, but for many people, therapy can be nerve-wracking and anxiety provoking. To sit down with a stranger and tell them about the inner working of your mind, your problems and struggles, and your worries is no small task. This becomes even more difficult for people who have a diagnosis such as anxiety that makes them worry even more than the average person. One way to ease a client into the therapeutic process with as little anxiety and worry as possible is to provide them with a clear image of what to expect. If the client knows ahead of time what their goals are, what they can expect to work on in the session, and what homework they will be going over, they may feel more prepared for the session. Similarly, someone who has experienced trauma may struggle in situations where they feel they have very little control. By offering a structured session with an agenda that the client contributes to collaboratively, you give the client control over the session and avoid surprising them making them worry about what their next session will be like.

    Another important aspect of a structured session for CBT is that is assists the therapist in ensuring everything important for that session is covered. For example, if a session begins with no structure or guidance, the therapist and client might go down a path about one thing that happened within the past week. Although it is important to touch base of recent events and possibly add them to the agenda, with no structure, this could easily take over a whole session. In this case, the client might talk about one issue for the whole session, and that issue might not relate to their treatment plans or goals what so ever. This means that little progress towards actual goals were made, and it prevents the sessions from being as effective as they could be. This could also mean that the end of the session comes before there was time to go over the previous week’s homework. As explained in our readings, not going over homework can damage the therapeutic relationship. If a therapist asks a client to take time out of their days to complete work for something they say is important, that work must also be valued as important enough to discuss and cover during a session. If not, a client may feel there is no point in completing homework going forward, and may believe that the therapist has wasted their time.

    As with anything in therapy, flexibility remains important. There is always a chance that something has come up that will take precedence and the therapist will have to move around items on the agenda in the moment. However, by having an idea for an agenda, the therapist can come to the session prepared by reviewing information on the client, and with a reminder to not skip over any important aspects such as checking in on the client at the beginning or receiving feedback at the end. By sharing the agenda with the client towards the beginning of the session, the therapist can also turn it into a collaborative process, making sure the client has a say in what they think is important to cover in the session. This collaboration once again allows the client to recognize their very important active role in the therapeutic process, and will help them to remain engaged.

    Reply

    • Lina Boothby-Zapata
      Feb 06, 2021 @ 15:42:22

      Hi Christine,

      Thank you much for your thoughts about the importance of having a structured interview. Reading your post made me think about the therapist’s organization skills and how this can contribute to the therapeutic relationship. I like the examples you brought about clients coming to therapy because their lives have been disorganized and conflicted. Having a session without structure could cause the client to decline a second session. Contrary to my post, I tried to address the importance of a structured interview for the therapist. Knowing that if there is a “map road” to follow during our future internship that we can utilize and apply during our sessions provides me with great relief and confidence because I will be able to prepare my session and make a plan for the client in terms of therapy. I am sure having all these fundamentals will make our practice thriving. Another element is that J.Beck recommended is learning the basics first in the clinical practice and then go to the CBT complexity.

      Reply

  21. Tim Cody
    Feb 04, 2021 @ 15:40:45

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

    My understanding of the therapeutic relationship is that it is effective for receiving the best treatment. It is important to establish rapport with your client, which means to build trust between the client and therapist. The earlier rapport is established in therapy, the better the chances of building the therapeutic relationship. The stronger the trust, the better the relationship, the more positive the outcome will be. Granted it does not do to dwell on the relationship alone. In fact, it should a goal of both the client and the therapist to eventually not rely on the help of the therapist anymore. They should come to a point where the client is well equipped to taking care of themselves and their mental health. Until the client is ready to tackle their mental health problems on their own, they must work together with their therapist. One concept they will focus on using is collaborative empiricism. The goal of collaborative empiricism is to identify the maladaptive behaviors with the client and to test for their validity and utility. It is important for the therapist to understand they alone do not provide all the answers for solving the maladaptive behavior. But rather, the client and therapist work collaboratively and mutually. The therapist will at first appear to nudge or influence in the right direction, but overtime, the client should be able to grasp the skills they have used with their therapists in their session in the real world.

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

    It is important to have session structure for a number of reasons. First off, it shows your client that you know what you are doing. In order to develop rapport with your client, you need to be able to show them three characteristics: expertness, trustworthiness, and attractiveness. If you appear that you are an expert in your field and confident in your practice, show that you respect your client’s confidentiality, and are a likeable person, you will establish rapport with your client. Having structured sessions with your client shows that you are an expert in your profession, so you are more likely to establish rapport if you have session structure. Secondly, structured sessions allow for provided direction between the therapist and the client. It enables you to see your client’s progress and what the outcome will be provided the structured sessions are followed appropriately. It also allows therapists to stay on topic and not veer off on a tangent. Third, session structure allows the client to be exposed to CBT and how effective it is. Some sessions will require more structure than others, while some sessions will need to be unstructured in order to gear towards your client’s needs. This is what CBT is all about: establishing rapport with your client and exploring their problem together and focusing on a collaborative solution. These structured sessions will allow for focused and efficient CBT therapy, and even allow for unstructured conversation when necessary.

    Reply

    • Abby Robinson
      Feb 04, 2021 @ 17:50:23

      Hi Tim
      I like how in your description of collaborative empiricism you noted that the job of therapist is not have all the answers and goals for the client, but rather work as a team to come up with appropriate goals. I think this is a really important part to note because, as you mentioned, the client should be able to come up with and use these goals on their own (eventually) in the real world. This is important that there is collaboration because if the therapist were to come up with all the goals and treatment interventions on their own, the client wouldn’t be as resourceful on their own. The goal of CBT would be to have the client be able to take the things they learned/worked on in sessions and apply it to the real world, so collaboration is key!
      See you in class!

      Reply

    • Cassie Miller
      Feb 05, 2021 @ 18:29:17

      Hi Tim,

      I feel like you really hit the nail on the head with session structure in that it provides a direction for the therapist and client. A lot of the time people tend to focus on this technique helping the therapist, but really it allows the client to feel more comfortable. There are less awkward silences and the client can really tell that the therapist is organized and has a plan for them. It also shows that you are taking the time to develop structure for your client that extends past the therapy session. An example of this is providing the client with homework. I also liked how you mentioned that it keeps the therapist on topic because it is easy to get lost in the session, especially if the client has a lot of information to share (which is very common). In my own past experiences with therapy there have been times where I wished the counselor was better at steering the session. If they do not pull out the main ideas and focus on a proactive way to start making progress, you leave the session feeling as though you have talked about a lot of stuff, but still have no tools to start working on these issues.

      Reply

  22. Nicole Giannetto
    Feb 04, 2021 @ 15:46:33

    (1)
    One of the most important aspects of CBT is the establishment of the therapeutic relationship. The therapeutic relationship in CBT treatment is one that strives to be balanced and dyadic. A key focus for CBT therapeutic relationships, as well as other psychological interventions is for the clinician to establish and maintain the idea to their clients that although they are considered a professional in their study, it does not mean that they are “all knowing” and will bring all the answers to the treatment. Instead, it is crucial to inform the client that treatment will be based on a balance of contributions between both clinician and client to establish common goals in treatment. This type of relationship is defined as collaborative empiricism, and encourages a working relationship between clinician and client throughout the entirety of the CBT intervention.

    (2)
    The purpose of having a structured session for effective CBT is rooted in the idea that this type of therapy strives to be both purposeful and flexible. The goal is for the client to get the most out of each session without rushing through their treatment. Having structured sessions throughout treatment will socialize the client to CBT. For new clients, CBT is often going to be something they need to gradually become educated on and comfortable with using. The early sessions are important for establishing that secure base to prepare both client and clinician for the therapeutic journey. During this stage the client’s goal is to obtain information from the client’s past and identify their current symptoms. Doing this will help the clinician brainstorm with their client to create an agenda that they can work off of throughout treatment. This agenda can be adapted to fit the relevant problems and their corresponding treatment goals. The culmination of these early sessions will result in the client receiving homework to complete for the next session. The middle sessions will consist of the clinician obtaining current information of the client’s mood and symptoms and reviewing the homework that was assigned. The homework is a crucial part of CBT treatment because it continues therapy outside of sessions and encourages the patient to work on their skills during their daily activities. Review of homework will then be followed by the clinician providing a summary of the client’s progress and offering feedback, as well as encouraging the client to provide their own feedback on how treatment is going for them. The final part of treatment in sessions will consist of obtaining the client’s symptoms and mood, and summarizing and reviewing the progress and accomplishments throughout treatment.
    By having sessions structured, it may offer comfort and clarity to the client that their treatment is mapped out and ready for them if they are ready themselves. Sometimes, treatment can seem daunting, because the endsight does not seem so clear and attainable. By educating the client on the stages of treatment, that end goal seems more attainable, because the client is aware that each stage will prepare them for it, and may be comparable to experiences in school, where the student will attend classes and study throughout the semester to achieve their goal of ACEing that final exam.

    Reply

    • Yen Pham
      Feb 06, 2021 @ 13:26:11

      Hi Nicole,
      I like the way you discuss the importance of session structure. You brought great details on your answer such as the role of the therapist and the progress of each session. I agree with you this is beneficial for both, the therapist and the client. This
      helps the therapist be more time efficient and helps the client begin to understand what they can expect from each session. Such structuring, whether explicit or implicit, gives evidence of the therapist’s expertness. Since the client perceive that the therapist knows what he is doing, explicit structuring may be more effective than implicit structuring. There is some evidence that explicit structuring does enhance counseling effectiveness. Structuring also enhances the therapist’s informational influence.

      Reply

  23. Abby Robinson
    Feb 04, 2021 @ 15:55:47

    Therapeutic relationship in CBT is important because establishing a healthy, collaborative team will yield better results for treatment. Throughout CBT, the client and the therapist will be actively participating in the sessions to work together to accomplish the client’s therapeutic goals. In this collaboration, CBT techniques and interventions will be included in these sessions by using the information provided by the client. A good therapeutic relationship starts with nonspecific factors. These factors include things like being empathetic, non-judgmental and genuine. These factors are seriously important in creating a good relationship with the client because the client will want to feel like they are being validated and understood. Being empathetic gives the client a sense of how their therapist understands where their feelings are coming from, without being judged. This is important for CBT because the therapist can get a sense of where these maladaptive thoughts and feelings are coming from, through the information the client is giving them. It is also important that the therapist is genuine and non-judgmental because if the client says something that is extreme or gives off strong emotions, the therapist would want to be self aware of their reactions to this information so that the client doesn’t feel judged. If the client feels judged, they may not feel comfortable talking about personal things, which is important for CBT. The therapeutic relationship in CBT also builds on interpersonal skills such as attractiveness, expertness and trustworthiness. These skills are important for a strong relationship with the client because the client should feel comfortable talking about personal things in detail. The therapist should come off as likeable and that there is compatibility between them. Also, the therapist should explain to their client the process of CBT and how to come up with reachable, appropriate goals to show their expertness. This helps the client know they are “good hands” and that their therapist knows what they’re doing. Collaborative empiricism is important and specific to CBT. A specific feature of collaborative empiricism is the understanding of therapist client activity level. Therapist client activity level is when throughout the process of CBT, the level of participation from the therapist and client in sessions will fluctuate. This is a collaboration of both members, but in the beginning, the therapist is likely to have a lot of information to give, goals to set and so on so they will have a high activity level in the beginning sessions. Whereas towards the end of the CBT, the client will have a high activity level in the sessions because they will have become more autonomous and more independent. Another feature of collaborative empiricism is client specific factors. These are factors that make up what the client facing on a daily bases. Presenting symptoms is a feature of client specific factors where the client has a challenging or maladaptive behavior that can be challenging to the therapeutic relationship. This is important to CBT because the therapist needs to be able to adjust his or her own thoughts and feelings about this presenting symptom in order to focus on treatment. Another client specific factor is their environmental stressors. These are experiences that they may or may not have control over but are greatly affected by it. For example, loosing their job or being diagnosed with a serious disease. This is important to CBT because the stressor will effect the treatment goals depending on whether the client had control of the event of not. Lastly, a feature of client specific factors is sociocultural factors. This is important because the therapist need to be aware of any biases they may have with will effect the treatment and relationship. The last factor of collaborative empiricism is conceptualization and treatment. This is important to CBT because the therapist needs to be aware of the important information the client gives to come up with the most beneficial treatment plan. The client should also be “on board” with this plan as there will be a more positive outcome if they are in agreement of their goals.

    Reply

    • Abby Robinson
      Feb 04, 2021 @ 17:43:47

      Forgot to answer the second part- sorry-
      Session structure is important for CBT because it adds a sense of security, in a way, when a client is feeling vulnerable or distressed in beginning sessions. Having structure shows the client that there is purpose to what they are doing in therapy and that the therapist is invested in helping the client accomplish goals. Structure also helps clients and therapist stay on track and allows them to make any modifications if necessary. This is especially important for CBT because this is a collaborative process. Having a structured setting gives a solid foundation of the process and keeps the sessions moving forward. If a therapist doesn’t structure their sessions and doesn’t plan- the client may feel like they aren’t important to them and that the therapist isn’t invested in their therapeutic process.

      Reply

    • Connor Belland
      Feb 04, 2021 @ 19:52:14

      Hi Abby, I really like wha you said about structuring of a therapy session should be both purposeful and flexible. While it is important to keep structure in a session to try and keep the client engaged and on track to meet their goals, it is also important to be flexible with this structure. Treatment plans are always changing and evolving based on the clients needs, plus you never know when something new comes up in a session and the structure is derailed, so it is important to allow room for these situations.

      Reply

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Adam M. Volungis, PhD, LMHC

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