Topic 3: Therapeutic Relationship & Session Structure {by 2/6}

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 2/6.  Have your two replies posted no later than 2/8.  *Please remember to click the “reply” button when posting a reply.  This makes it easier for the reader to follow the blog postings.

39 Comments (+add yours?)

  1. Jessica Costello
    Feb 02, 2020 @ 17:04:41

    1. Contrary to myths, CBT does not lack empathy. Though clients can still make progress if the relationship with their therapist hits some setbacks, strong therapeutic alliance strongly relates with the quality of therapy and client outcomes. In CBT, the client and clinician work together to decide on goals for treatment, collect data on what the client has already tried and how he or she is feeling, and formulate specific interventions. The client is regarded as an expert on his or her own life, and the clinician functions to reflect automatic thoughts and core beliefs to hopefully motivate the client to change.

    Trust is a major component of a relationship grounded in CBT. As the client trusts the clinician with potentially embarrassing or personal information, the clinician also trusts that the client will understand or make an effort to understand the underlying purpose for therapy, the cognitive model, and what will go on both inside sessions and outside as he or she completes homework.

    Collaborative empiricism means that clients and clinicians will work together on case formulations and establishing goals, with shifting levels of work for each partner in the relationship as therapy progresses. For example, at the beginning of therapy, the clinician will be doing more work to make connections between pieces of information from the client, make tentative interpretations and case formulations, and provide the client with psychoeducation as well as an explanation of how therapy works. But as therapy moves forward, the client will be picking up much of the mental labor as he or she may keep a thought record, challenge negative beliefs, or practice new behaviors outside sessions. The results of this process will allow both the client and clinician to evaluate the success of the interventions and decide how therapy will move forward. Towards the end of therapy, the client will play a larger role in setting the agenda.

    2. Structured therapy sessions benefit both the therapist and the client. At the most basic level, keeping sessions structured allows them to stay focused on the presenting problems and have thorough discussions. Structure also further familiarizes clients with the theory of CBT and reminds them that therapy isn’t simply a place to vent about all stressors.

    Ensuring that the clinician always checks in with the client by reviewing their previous week at the start of a session helps keep the therapeutic alliance strong. By keeping a firm structure, clinicians can check in on client progress and decide if the interventions are working. It especially ensures that there’s time to complete tasks like checking on how the client is doing with their homework and reviewing specific moments from the intervening week that may have stood out to the client and provoked some insight. Leaving time at the end also allows the client to ask any questions and offer feedback, which will in turn influence the next session.

    Reply

    • Melanie Sergel
      Feb 04, 2020 @ 12:45:40

      Hi Jess,
      You did a great job discussing the therapeutic relationship in CBT. You also did a good job explaining collaborative empiricism. I agree with your point that structured therapy sessions can benefit both the therapist and client. I think some people don’t realize that it is very beneficial for the therapist. It is important for clients to become familiarized with CBT and therapy because if there was no structure, the client would not know what each therapy session would be like. I like how you discuss that it is important for therapists to start the session by reviewing the previous session. This can point out what the client has completed, where we are now, and where we are moving next. I like that you touch upon leaving time at the end of the session. It is very important to leave time at the end for the client to address anything they need to before leaving because you do not want time to be up without closing the session with the client. It is very important to not send clients away at the end when they still need to talk about something or are confused because a lot can happen until they see you next time. Good job!

      Reply

    • Monica Teeven
      Feb 05, 2020 @ 13:58:11

      Hi Jess! In your response to question one, there was an important factor about collaborative empiricism that I did not discuss in my blog post. I mentioned how the activity level between the client and the clinician is an important element in collaborative empiricism, however you discussed how the activity level shifts for the client and clinician overtime in therapy. You discuss how in the early stages of therapy the clinician would be doing most of the work, whereas overtime, the client would begin to be the one who is putting more effort. Then you provided examples to the reader as to why the clinician and the client’s level of work shifts overtime in therapy, which helps the reader see how and why this shift occurs. For your response to question two, in addition to session structure helping the client’s familiarizing themselves with CBT, it also shows the client that you as the clinician exhibit trustworthiness, expertness, and attractiveness which can also help establish a good therapeutic relationship. Both of your responses to the questions were great Jess!

      Reply

  2. Renee Gaumond
    Feb 03, 2020 @ 16:03:58

    (1) What is your understanding of the therapeutic relationship in CBT (include collaborative empiricism in your discussion)?
    The therapeutic relationship is very important to the client’s progress in CBT. The therapeutic relationship is the relationship between client and clinician. This relationship has a strong impact on the therapeutic outcome of clients. Cultivating a positive alliance where both the client and the clinician work together in order for the client to make adaptive progress is essential for favorable outcomes in CBT. The therapist-client activity level is different compared to other types of therapy. In CBT, clients and clinicians work together toward a goal, while in a lot of the other types of therapy, the clinician does most of the work. The relationship is best worked on in the first few sessions, research shows that a strong relationship within the early session is related to favorable outcomes in CBT. Showing empathy, genuineness, and unconditional positive regard is an effective way to boost the therapeutic alliance. These skills let the client know that the clinician will support them in a non-judgmental manner. The client’s thoughts and feelings will be taken as they are and will be worked through.
    Collaborative empiricism is a key factor in the effectiveness of CBT. Collaborative empiricism is a process of identifying maladaptive cognitions and behaviors and challenging them for their validity. Other factors are important too, but they only enhance CBT, while collaborative empiricism is what makes CBT effective. Without identify and changing the maladaptive cognitions and behaviors of the client, CBT won’t be effective. The goal of CBT is to change those maladaptive thoughts and behaviors in order to make therapeutic improvement.

    (2) Why is it important to have session structure for effective CBT?
    Session structure is important in CBT. It offers the client and clinician a direction to go with therapy. When the sessions are structured, they become a way to focus on current problems and goals. The structure allows for the client and clinician stay on track with the goals that the client is setting. It also allows the clinician to have a formula for when they are unsure where to go during the session. It comes off as more clinical than random.
    Another reason why structure is important is that it’s essential for the client to be able to build the skills necessary to be able to provide therapy on their own without the help of the therapist. The structure helps the client know that there is eventually an end to therapy and that they will gain the skills they need to cope and function on their own.

    Reply

    • Jessica Costello
      Feb 04, 2020 @ 09:50:42

      Hi Renee! I like the way you summarized the role of collaborative empiricism and identified unconditional positive regard, genuineness, and empathy as the ingredients to a strong therapeutic relationship. You also made a good point about structured therapy reminding the client that CBT is time-limited and has an ending point. Facilitating clients’ practice of skills outside sessions is exactly what we want to do as therapists so it’s interesting to see the timing/layout of sessions as a way to do that. Great job!

      Reply

    • Melanie Sergel
      Feb 04, 2020 @ 14:08:27

      HI Renee,
      You did a good job explaining the importance of the therapeutic relationship. I agree with you that collaborative empiricism is a key factor in the effectiveness of CBT because CBT will not be effective if the therapist and client do not work together to identify maladaptive cognitions and behaviors to challenge them. You make a good point about session structure allowing the clinician a formula for when they are unsure where to go during the session. It is a template for them to build and work off of. Another good point you made is that structure does help clients be able to build their skills so they can become their own therapist. It also does give the clients optimism to know that they will not be stuck in therapy forever and they will be able to get through it.

      Reply

  3. Robert Salvucci
    Feb 03, 2020 @ 18:35:02

    1. The therapeutic relationship in CBT is centered around building a trusting, collaborative relationship. Strong therapeutic rapport characterized by trust, empathy, mutual regard and collaboration are essential foundational pieces in making effective progress. Many of the skills we practiced in Counseling Principles go a long way in establishing a relationship. These include active listening, cultivating genuine interest, open body language, asking attentive and relevant open questions, among many skills. While our position as a professional is recognized in the context of the relationship, we are not considered to be experts on a client’s needs. Clients are viewed as autonomous and it is our job to understand their goals and work with them to set new goals and make progress in the context of CBT processes. Psychoeducation is offered in describing the therapeutic process and in other instances where we feel it may genuinely benefit a client.

    Collaborative empiricism is the process of mutually setting and working towards therapeutic goals. The client become more active as therapy progresses, and the therapist remains active in keeping sessions focused and working together towards solving relevant problems and identifying cognitive distortions and core beliefs which contribute to distress. Both parties work together in conceptualizing the sources of client distress, and empirically testing the validity of cognitions and beliefs that cause or maintain distress.

    2. Session structure holds both the client and therapist accountable for making progress towards identified goals. Given that therapy sessions only last about 50 minutes, it is important that sessions are organized to be efficient in identifying modifiable sources of distress in each client. Structure also serves to familiarize clients with the important concepts of CBT and helps implement the understanding of the concepts into the therapeutic process, and ultimately generalize into day to day life. Structure can also instill a sense of hope and direction for clients, increase perceptions of the therapist as competent, and provide a framework for moments when conversation seems forced or not relevant to therapeutic goals.

    Structure also ensures that clinicians are checking in with client goals, emotions, and relevant concerns/feedback within session. These components serve to strengthen the therapeutic relationship and ensure that both parties are on the same page. It also allows an opportunity for clients to clarify any questions or concerns that they have regarding the therapeutic process. Goals can also be modified relevant to any novel presenting concerns. Structure provides a framework for collaborative empiricism and keeps sessions focused on areas that are most relevant to client well-being and presenting concerns.

    Reply

  4. Erin Wilbur
    Feb 03, 2020 @ 18:51:20

    1. One of the most important parts of CBT is a therapeutic relationship that allows the client and therapist to work together as a team, rather than viewing the therapist as an expert with answers to any problem. This means that the client is an active participant in therapy and therefore their own recovery. The client is also treated as an expert in their own life, with information provided to the therapist to help build treatment goals and plans. This team of the therapist and client work together to reach the client’s goals. Collaborative empiricism is defined as an action-oriented therapeutic alliance driven by research that integrates, tests, and modifies clients’ thoughts and behaviors. This is the perfect description of two core pillars of CBT, that it is an evidence-based practice, and an alliance between the client and therapist. This is also very helpful for evaluating the client’s progress, as the therapeutic alliance that has been built is used to measure how the client is modifying their thoughts and behaviors to make positive change and combat maladaptive thoughts and beliefs.
    2. Session structure is essential for effective CBT because it offers hope to the client while also providing a set schedule for both the client and therapist to follow. CBT is a time-limited practice, so having sessions follow the same structure each time is essential for tracking progress throughout therapy, whether for long-terms goals or just to check in about last session’s homework. Having structure also allows the client to become used to the process of CBT as well as ensuring there is a set direction for the therapist and client to follow. This structure enhances therapy because it emphasizes the importance of focusing on the relevant goals and interventions that will be most helpful to the client.

    Reply

    • Jessica Costello
      Feb 04, 2020 @ 09:56:31

      Hi Erin! I liked how you connected collaborative empiricism to evidence-based practice and the larger theory and goals of CBT. The fact that the structure of the client-therapist team could be based on research wasn’t something I had considered. You said the alliance could be used to measure how the client is modifying their thoughts; I think the alliance could also change as the client progresses through treatment, especially towards the end when they are taking even more of an active role. Good job!

      Reply

    • Shelby Piekarczyk
      Feb 05, 2020 @ 16:03:16

      Hi Erin,

      I completely agree that the therapeutic relationship is essential for CBT. Without a strong relationship between therapist and client there would be minimal progress within each session. I agree with your statement that CBT is a collaboration between the therapist and client, working together as a team. I also really liked your comment about the client being a ‘pro’ in their life. I think this statement is very true because even though therapists have empathy, and learn about the client, the client is ultimately the person living the life and the professional. Lastly, I agree with your comment about session structure, CBT is a time-limited therapy so structure to each session will help the flow of therapy and keep therapist and client on track.

      Reply

  5. Melanie Sergel
    Feb 04, 2020 @ 12:34:39

    1. There is much data that shows that there is a correlation between a strong therapeutic relationship and treatment outcomes. The therapeutic relationship in CBT is very important. The therapist and client work together in CBT towards mutual goals that they have set together. In order for the client and therapist to work together effectively, a therapeutic relationship needs to be established. Empathy, trust, and genuineness are major factors that contribute to building a strong therapeutic relationship in CBT. A client is not going to open up with a therapist if the client feels that the therapist is not trustworthy or cares about the client. As a therapist, conducting yourself as an expert can help the therapeutic relationship because clients are more likely to be engaged and willing to challenge their own maladaptive thoughts and behaviors, when they perceive their therapists as competent. Showing unconditional positive regard is also important in this relationship because it helps the client know that he/she can trust you so they can fully open up about his/her problems.

    An expectation of CBT is that both the therapist and the client are active participants throughout the process. There needs to be a strong therapeutic alliance in CBT in order for the client and therapist to be collaborative. Collaborative empiricism is an action-oriented therapeutic alliance that integrates, tests, and modifies clients’ thoughts and behaviors. Collaborative empiricism is the key therapeutic alliance factor that promotes the overall empirical effectiveness of CBT. This is used to identify maladaptive cognitions and behaviors and then test the validity of them. With collaborative empiricism, the therapist is able to slowly adjust the client overtime to become more independent and piece together things on their own.

    2. Having session structure is important for effective CBT. Session structure is important because it shows the client that there is a plan for each session, so the client will not be walking into something new and different every time. Session structure also helps keep clients and therapists focused on the goals they need to reach by the end of therapy. It also can help keep the focus on the presenting complaint and not drift away discussing things that are not important. It can give comfort to the client, and most clients want and need this structure. Most clients need to feel the need for comfort because therapy can intimidate and cause a client to become anxious. Keeping structure in therapy can also show the client that the therapist knows what they are doing and that they are trustworthy.

    Reply

    • Madison Armstrong
      Feb 08, 2020 @ 19:49:22

      Hi Melanie,
      In your post you discus the importance of trustworthiness and I agree that this quality is extremely important when building a therapeutic relationship. To me, trust is important in building any kind of relationship and especially a therapeutic relationship. When you are going to therapy, you would definitely want your therapist to be someone that you trust because without trust you would not want to share your inner thoughts and emotions. When sharing this private information about yourself, it is important to know that you will not be judged and that your feelings and thoughts are valid.

      Reply

    • Tim Keir
      Feb 09, 2020 @ 20:08:35

      Hey Melanie!

      Excellent work on your description of the therapeutic relationship. Clients have to trust that we know what we are doing and that we are working in their best interest. If they don’t trust that we are working hard in the relationship, then how will we? You captured this well in your collaborative empiricism.

      I love your understanding of why there needs to be structure in session as well. It seems like you connect it to the therapeutic rapport, in that it adds a high level of credibility and trust into the relationship to have proper structure set. Great insight!

      Reply

  6. Shelby Piekarczyk
    Feb 04, 2020 @ 14:52:06

    1. The therapeutic relationship is extremely crucial from the beginning of therapy until termination. When conducting your therapy session, it is important to develop a therapeutic relationship, so your client feels genuinely cared for, leading to a higher trust in their therapist and willingness to work towards change. Empathy towards your client is an important tool for a practicing therapist because it helps put themselves in the client’s shoes. To me, empathy is one of the most important things in the therapeutic relationship because it will convey to your clients that you deeply care and understand their struggles. Additionally, having proactive sessions, with session structure will show your client your effectiveness, trustworthiness, and attractiveness leading to positive feelings for you as a therapist, strengthening the therapeutic relationship. Within CBT it is important for the client to feel cared about because the key to effective treatment is an alliance between the therapist and client. Developing a trustworthy, strong therapeutic relationship will lead the client to trust their therapist, being more proactive in the therapy process. Collaborative empiricism is an active-oriented therapeutic alliance that changes client’s thoughts and behaviors. Collaborative empiricism is heavily influenced by research, based on this therapeutic alliance. Within the therapeutic alliance the therapist and client work together towards client change. Because of this as stated earlier, the therapeutic relationship is crucial. For the client to trust their therapist and work together towards change, they must believe their therapist genuinely cares for them and their journey towards recovery. If this therapeutic relationship is never developed or lost within treatment, effective outcomes will not be obtained.

    2. It is important to have session structure because it shows to your client your effectiveness, building trust and a strong therapeutic alliance. Having session structure also provides a direction for you and your client, giving you a clear path to follow for maximum outcomes. Session structures will also help to minimize distractions and keep both you and the client on the right path. When structuring your sessions, it is important to acknowledge where you are in sessions (pre-session, early session, middle session, and late session). Correctly structuring your therapy sessions will depend on where you are in your sessions. Additionally, having an agenda set for each specific session will demonstrate to your client that there is a plan for this session and goals you need to accomplish. Within CBT the therapist wants to reach adaptive and positive thoughts/behaviors in their clients, ultimately leading to termination of sessions. Developing a plan of action and sharing this with your clients will help to positively impact the therapeutic alliance, showing your clients that you have a plan moving forward in each session.

    Reply

    • Ashley Foster
      Feb 04, 2020 @ 16:27:43

      Hey Shelby!
      I totally agree with you on empathy being one of the most important key qualities a therapist should have. Empathy is something I believe is not taught, rather a quality that we share to better understand our situations even though we might not have gone through it ourselves. I also like how you mention a benefit to session structure is having a clear path for our client in treatment. The term describes the simplification of what needs to achieved in session and pushing the rest to the side. Great job with the post!

      Reply

    • Erin Wilbur
      Feb 05, 2020 @ 14:51:41

      Hi Shelby,
      Your emphasis on empathy and it’s impact on therapeutic relationships is really important. You’re absolutely right that if our client doesn’t believe we care for them, then they won’t be willing to work with us toward positive change, so displaying empathy and gaining our client’s trust as early on as possible in therapeutic relationships is essential for effective CBT. You also make a good point that structuring sessions shows our client we have a “plan of action” for them. I like the way you said this because it emphasizes the importance of showing our client that we’re taking their problems seriously and that we’ve developed a plan to help them reach their goals. Good job!

      Reply

  7. Jenna Nikolopoulos
    Feb 04, 2020 @ 14:53:42

    1. The therapeutic relationship in CBT is one of the most important parts of therapy because without a good relationship with the client, it will be hard for the client and counselor to work together. In CBT, the client is expected to be an active participant in each session and to work together with the counselor to create goals that the client wants to focus on and in order for this to happen, there needs to be a good therapeutic relationship established in the beginning or else therapy will not be as effective as it could be. To establish this relationship, the counselor needs to show certain traits to the client, such as empathy, genuineness, and unconditional positive regard. These qualities will help the client trust the counselor, thus facilitating the therapeutic relationship. If the client doesn’t trust his/her counselor, then he/she will not be as willing to share personal information about themselves. In CBT, the client is considered to be an expert on his/her own life and the counselor is there to challenge and cause the client to recognize his/her own maladaptive thoughts, behaviors, or emotions so he/she will be more willing to make changes in the future.

    Collaborative empiricism is defined as an action-oriented therapeutic alliance driven by research that integrates, tests, and modifies clients’ thoughts and behaviors. This helps to promote the effectiveness of CBT because there are certain techniques the counselor can use to allow him/her to identify and test the validity of the maladaptive thoughts and behaviors in the client. Once the client is able to recognize these maladaptive patterns, he/she can begin to work on changing them to more adaptive thoughts and behaviors. Collaborative empiricism is also helpful in examining a client’s progress throughout therapy as the counselor can use assessments periodically to see if positive modifications are being made to a client’s thoughts and behaviors. If not, then the counselor has to evaluate why that is the case and change the course of action to better suit the needs of his/her client.

    2. It is important to have session structure for CBT to be effective because clients will feel more comfortable with the idea of therapy if they know what to expect from the counseling process and understand the role they play in therapy. This is important as it helps the client to trust his/her counselor, which causes him/her to be more willing to be an active participant in sessions. Structure also allows the counselor and client to have a plan that is to be followed throughout each session, which helps put the client at ease, as they know what to expect, and makes therapy efficient. Since CBT is a time-limited practice, counselors and clients need to make the most of their time together. By structuring sessions, counselors are able to better track their clients’ progress throughout therapy and makes sure that both the counselor and client are focusing on the tasks at hand and the goals the client wants to reach.

    Reply

    • Monica Teeven
      Feb 05, 2020 @ 14:15:27

      Hi Jenna! In your response to question one, there was an important factor that I did not mention in my response to this question, but is important. You discussed that the clinician needs to exhibit particular traits to the client such as empathy, genuineness, and unconditional positive regard in order to establish a therapeutic relationship. To your response to question two, you mentioned how session structure helps the client to know what to expect in therapy. This is absolutely true. However, having persistent session structure also enables the client to learn CBT by familiarizing them with this kind of structure. Great blog post this week Jenna!

      Reply

    • Erin Wilbur
      Feb 05, 2020 @ 14:42:11

      Hi Jenna,
      I like your emphasis on the client’s role in therapy and why a therapeutic relationship is necessary for the client to become involved. In order for the client to be an active participant in treatment and feel comfortable sharing aspects of their lives that we deem them the “expert” in, they definitely need to trust us. If there isn’t a good therapeutic relationship, the client has no reason to believe that CBT will be effective and that their therapist can help them, because they will not feel comfortable. I also like the stress you place on trust that comes from the routine of having structured sessions. Helping the client know what to expect by following the same schedule each session is just another way to build a therapeutic relationship and show our clients that we are trustworthy.

      Reply

    • Shelby Piekarczyk
      Feb 05, 2020 @ 16:07:12

      Hi Jenna,

      I agree completely with your comment that a therapeutic relationship is an essential part of therapy and if this is not gained at the beginning of therapy that continuing sessions could potentially struggle. Showing your client that you are there for them and also displaying that they are the professional in their lives and as active part of therapy is a crucial part of CBT that I agree could not be attained without a strong therapeutic relationship. I also agree that session structure is crucial, showing your clients what they will be responsible for along with displaying future sessions and what to be expected.

      Reply

    • Renee Gaumond
      Feb 06, 2020 @ 18:26:02

      Hi, Jenna,
      I agree with you when you said that “there needs to be a good therapeutic relationship established in the beginning or else therapy will not be as effective as it could be.” An important part is to establish that relationship in the beginning for the client to come back to the sessions. If a client doesn’t feel motivated to go to therapy, then it might be due to a lack of therapeutic alliance. The second part when you said that therapy won’t be as effective is very true when it comes to clients not wanting to come to sessions. When they don’t come to sessions, the track of progress will be affected and if they don’t come at all, then the clinician loses a client who could benefit from treatment.

      Reply

  8. Ashley Foster
    Feb 04, 2020 @ 15:36:24

    1. The therapeutic relationship in CBT is one of the key components to successful treatment even though it is not a primary focus. To be successful in a relationship, the therapist must have certain qualities. Rogerian qualities such as empathy, unconditional positive regard and, genuineness helps in welcoming change within the client. Interpersonal skills such as expertness, trustworthiness, and attractiveness help in making the client comfortable in the care they are in. The collaboration of these skills combined with the phase in which the relationship is at defines the relationship and the level of activity from the two parties.
    In the beginning/ early phases of treatment, a higher demand of activity is on the therapist as the relationship is just blossoming. The client in the phase is still held to engage in session even though their demands are much lower than the therapist to strengthen the bond. In the middle phase of treatment, the playing fields become more even as the relationship becomes more of a collaboration as the therapist demand decreases. The client takes on a more active role in their treatment with implementing skills in their everyday life outside of session. Finally, in the later phase of treatment, it should be more client led in action planning for problem solving as the therapist is seen as more of a facilitator.
    The more the client feels tended to by the clinician, the probability that the client will participate and have open communication is raised significantly. Consequently, the more exploration and insight the client can tend to, the greater the effectiveness in the action or treatment plan can be. Resulting in an increase of client participation in their treatment and a decrease in likelihood that the client will have to return to treatment as they will be more equipped to cope.
    2. Session structure is another key component to effective CBT. Sessions are limited in amount of time with clients. Keeping to a structure session, as therapist, we can use are time more effectively and focus on key problems that led to dysfunction. There is much work to be done during session so staying on session. The therapist has the ability to gather enough information needed to better understand and facilitate treatment to their clients. The client likewise in a structured session is more likely to walk away more fulfilled from session and have better outcomes in therapy as CBT is a time limited treatment.
    There are four phases that occurs within a session. These include pre-session stage where the reviewing of client information and pre-session assessment is done. This aids in making sure all the demographics are correct for a better understanding of the client for the therapist. The second stage is the initial or early session stage where check-in is completed, mood and symptoms are checked, an agenda is set, obtain an update, and review homework. This is in essence where we are seeing how the client is doing since seen last. The third stage is the middle stage where a review of problems alongside with problem solving, feedback and summarizing of session. This is where the work of specific problem and teaching of CBT skill that fits with the situation the client is in, following up with feedback, and working on any possible second problems. Finally, the late and end stage of session is where summarizing the session, assigning homework, and having a time for final questions and feedback. This is where the therapist checks in with their client to see how they believe the session went and summarize where they started. This structure aids in keeping relevance to the problems our clients are having and for the therapist to better correspond client’s goals and interventions to be had.

    Reply

    • Robert Salvucci
      Feb 05, 2020 @ 17:12:02

      Hey Ashley!

      It was smart to note that Rogerian qualities and interpersonal skills are effective when they correspond with the appropriate phase of therapy. Rather than the skills operating by themselves, they should be integrated with what is appropriate giving the stage in the session and the relevant goals. The analogy of the therapist as a facilitator towards the final stage was also helpful. Good job bringing in the themes of exploration and insight from Counseling Principles!

      Reply

    • Jenna Nikolopoulos
      Feb 06, 2020 @ 11:09:11

      Hi Ashley! I like how you break down treatment into beginning/early, middle, and later phases showing how the counseling process progresses over time since it’s important to realize that clients will not always be so forthcoming in the beginning/early phases until they are comfortable enough with the clinician to be an active participant in sessions. I see these different phases as a way to show how the therapeutic relationship develops. In the beginning/early phases, the client will not participate as much as they are learning to trust the clinician and the clinician will be guiding the majority of the session. In the middle phase, now that the client and clinician have established a good relationship, they are working together with the client participating as much as the clinician. Lastly, in the later phase, the therapeutic relationship has come to a point where the client is now taking the lead in sessions to come up with his/her plans of action and the therapist, though still helping, can take a step back and let the client problem solve on his/her own.

      Reply

    • Renee Gaumond
      Feb 06, 2020 @ 18:39:02

      Hi Ashley,
      I agree that clients are more likely to walk away satisfied from a structured session. The structure gives the client a sense that the clinicians knows what they are doing. It comes off as the clinician is organized and competent in their field. It allows the client to perceive the clinician to have expertise and confidence. I also agree that without the structure in a session, treatment wouldn’t be as affective because important parts of CBT can be missed or forgotten when there isn’t a format to follow. It would come off as random to the client and they wouldn’t know what to expect. If the sessions are structured, it will be easier for the client to learn that structure and be able to become autonomous without the aid of the therapist.

      Reply

  9. Monica Teeven
    Feb 05, 2020 @ 12:30:53

    1. The therapeutic relationship in CBT is not expressed as a necessity for change to occur in CBT. However, the therapeutic relationship needs to be viewed as positive by both the client and the clinician in order for the treatment goals to be reached and for the overall improvement of the client’s mental health and well being. Research continues to show that there is a positive correlation between strong client and therapist relationships and outcomes of treatment. There are both nonspecific and specific factors of CBT that discuss the imperative skills needed to form an effective therapeutic relationship with the clients. Nonspecific factors of the therapeutic relationship of CBT include the Rogerian features and interpersonal skills. These nonspecific factors are used across many kinds of therapy. The Rogerian features discuss empathy with CBT, unconditional positive regard with CBT, and genuineness and CBT. Interpersonal skills include: expertness, trustworthiness, and attractiveness. Specific factors of the therapeutic relationship of CBT supports collaborative empiricism and this form of empiricism is the main element in supporting the effectiveness of CBT. Collaborative empiricism’s main focus is to recognize maladaptive cognitions and behaviors and once recognized they are tested for empirical validity or utility. This process eventually leads to: the outcome of both adaptive cognitions and behaviors, a decrease in the level of frequency and severity of the current symptoms, and an overall enhancement of the client’s life. There are three important features in collaborative empiricism: activity level between the therapist and the client, specific factors about the client, and overall concept of treatment.
    2. There are many reasons why it is important to have a session structure in CBT in order for the therapy to be effective. One reason is that structure in sessions provides comfort and faith that therapy will be able to assist the client in being able to relieve some of their distress. In addition, it also shows the client that you as the clinician exhibit expertness, attractiveness, and trustworthiness. Persistent session structure enables the client to learn CBT by familiarizing them with this kind of structure. One way this is shown is by naturally displaying how to advance towards and solve a problem that is relevant to the client’s distress. Furthermore, session structure lets the clinician model the teamwork that is used between the client and the clinician when using CBT. This can include the clinician contemplating the client’s issues, being able to establish an appropriate goal, and to obtain feedback in order to make essential treatment modifications. Overall, session structure offers guidance to the client and clinician. In addition, sessions that have structure within the CBT framework increase the effectiveness of the therapy. This is because a therapy session that is organized stays on track with the problems that are most pertinent and coincide with the client’s goals and treatment interventions. Therapy that is efficient is important because the less time spent assisting a client lowers their distress levels and is better for the client.

    Reply

    • Robert Salvucci
      Feb 05, 2020 @ 17:27:03

      Hi Monica!

      Good job highlighting the difference between qualities that are important for therapy in general and skills that are more specific to CBT. These factors are important to keep in mind when approaching collaborative empiricism and potentially training in other therapeutic modalities.

      It was also important to mention how structure provides a sense of hope for clients. This sense of optimism and trust towards a clinician will keep therapy focused on what is most pertinent and relevant to goals, as you mentioned.

      Reply

    • Taylor O'Rourke
      Feb 06, 2020 @ 13:40:21

      Hi Monica!

      I like how you mentioned that the structure in therapy gives clients a sense of hope and faith. At a time where the client is coming to you in such a vulnerable, distressed state, it is so important that the therapist can provide some comfort in a way to let the client know that they are not going through whatever it is alone and that there are resources available to them for help. Many clients, especially those who are clinically depressed, may feel that there is no hope for them in feeling or getting better and this structure may provide them with something to look forward to. On the other hand, though, too much structure for some individuals may make them turn their heads away from therapy if they feel they are not in a place that they can handle something like this yet. I think it is important to look at it from both perspectives and recognize that some people may do better than others when it comes to a very structured, time-limited approach like CBT.

      Reply

  10. Mariah Fraser
    Feb 05, 2020 @ 23:15:56

    1. The therapeutic relationship is described as an alliance between the client and the therapist, as they both play an active role in working collaboratively toward mutual goals. Although both the client and therapist play an active role, throughout the course of therapy, these levels of activity fluctuate. Time and time again, research has shown that a strong therapeutic alliance has a significant impact on positive outcomes of therapy, just as a poor client-therapist relationship has significant negative impacts on the client’s well-being. There are multiple factors that can contribute to establishing a strong therapeutic alliance, including nonspecific factors. Nonspecific factors, such as Rogerian qualities (empathy, unconditional positive regard, and genuineness) and interpersonal skills (expertness, trustworthiness, and attractiveness) can greatly enhance the therapeutic relationship because the client feels supported.

    Collaborative empiricism is an action-oriented therapeutic alliance, where the therapist and client work together to set goals and figure out how to achieve those goals. The focus of collaborative empiricism is to identify maladaptive cognitions and behaviors, and then determine ways to test their validity. Unlike other therapeutic orientations, CBT views the client as the expert and therefore empowers them to gradually become more independent as they identify maladaptive cognitions and continue to test their validity on their own.

    2. Structure is important in CBT because most clients find it helpful to have structured sessions. Additionally, structure helps with the therapist’s interpersonal skills because they may be perceived as expert, trustworthy, and attractive to their clients, further strengthening the therapeutic alliance. Structure also provides direction, maintains focus on the problems of most relevance, and provides the opportunity for the therapist to model the collaborative nature of CBT.

    Reply

    • Madison Armstrong
      Feb 08, 2020 @ 19:39:28

      Hi Mariah,
      I agree with what you said about how session structure can also strengthen the therapeutic relationship by showing expertness. Structure shows the client that the therapist has been trained and can be helpful and directive during session. I love that in your discussion you talked about the significance that a strong therapeutic alliance has in research. Like you said, this relationship is important to seeing positive results in therapy and with a weak relationship the client may regress or even drop out of treatment.

      Reply

    • Tim Keir
      Feb 09, 2020 @ 20:13:59

      Hey Mariah!

      Excellent work in your description of collaborative empiricism, I feel you helped me understand the concept better. I appreciate that you mentioned how therapeutic rapport is not something that stays steady but can rise and fall within the context of treatment.

      Furthermore, I like how you linked structure in sessions back to building trust and therapeutic rapport! I think that is the best part of a structured session, in that it makes everyone more comfortable in knowing what to expect. Great job!

      Reply

  11. Tim Keir
    Feb 06, 2020 @ 00:00:35

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

    Long gone are the days of clinical and cold psychologists delving into the subconscious from the emotionally distant space behind the client’s couch. In a shocking twist, the field that attempts to promote emotional health involves creating an emotionally healthy relationship itself!

    Carl Rogers introduced ideas like unconditional positive regard to the field of psychology; that is, that clients require an environment where they are genuinely accepted in order for them to be comfortable enough to meaningfully explore their thoughts and emotions. Science and numbers have largely backed these ideas up. Still, most modern psychological theories do not find such emotional support enough in and of itself to spur positive change in all clients. Instead, the establishment of a positive therapeutic alliance paves the way for the client to try more demanding components of therapy.

    Thus, CBT sees the therapeutic alliance as a form of Collaborative Empiricism. The relationship is not only defined by creating a warm and accepting space to openly and safely discuss the clients’ problems, but also driven by a desire to test these problems and their associated cognition with a scientific rigor. There are three main aspects to combining therapeutic rapport with science. The first is the therapist-client activity level: in order for treatment to work, the therapist and client have to work collaboratively and actively towards the goals set. The amount of effort being put towards these goals should gradually shift from the therapist primarily to the client as they gain more skills. Second, the client-specific factors are the data that are to be used in this scientific process. The methods used in treatment will only improve from having a comprehensive assessment of the client’s presenting issues and environmental / social factors. Finally, the third component is the case conceptualization and treatment itself. The alliance of the client and therapist represent the joined efforts of experts in two fields: the client of their own experiences and the therapist in cognition and treatment. By working collaboratively, the two create a treatment plan that best represents scientific methods and the reality of the client in question.

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

    Cognitive Behavior Therapy isn’t designed to last for years and years, perseverating on the same topics and dreams in search of hidden subconscious urges underlying all unsightly behaviors. We ain’t got time for that. CBT runs a tight ship on a schedule, and by golly these maladaptive cognitive schemas are going to be addressed in a timely manner!

    To that end, a typical therapy session cannot be made up as you go. If that was done, then most of the time the client would likely end up either spending all of their time on only one of their concerns, or becoming so sidetracked that absolutely nothing of consequence to the treatment goals at hand was accomplished. So it is highly important for the counselor to establish an outline for session structure from the very first meeting.

    That isn’t to say that such structure must happen every time. There will be times when the session has to deviate due to outstanding circumstances in the client’s life. Perhaps a catastrophic event occurs which takes up the entire session. Perhaps a session structure is set up but a part of the process takes longer than initially anticipated. If it is deemed appropriate and beneficial for the client, flexibility can always be added to a session. It is important that the structure of a session be developed early so that the client can benefit from learning to focus on important topics and actively organize what they which to discuss. Yet ultimately the time is theirs to use, and should be used in a way that will be most productive for them.

    Outside of outstanding circumstances however, deviations from established structure should be gently interrupted and redirected. A client may go off tangent or begin to elaborate on a specific topic before truly considering what topics would be most valuable for them to explore. The counselor should feel comfortable in guiding the conversation in this way, both to assure that the time is used efficiently and to teach the client how to approach sessions.

    Reply

    • Jenna Nikolopoulos
      Feb 06, 2020 @ 11:44:41

      Hi Tim! I love how you described the importance of session structure for the effectiveness of CBT. I think it’s important to emphasize how a therapy session cannot be made up on the spot as the limited amount of time that the clinician and client have together could be used for purposes that aren’t productive to the clients needs and end up setting the client further back in progress since nothing of substance is being accomplished. I also liked how you mentioned how there will be times when the session has to stray from it’s original structure due to certain circumstances that occur in a client’s life. Sometimes things happen unexpectedly where the client has to prioritize those needs first before continuing with the original problem. The clinician has to be flexible when this happens to try to provide some sort of structure for the current session while also making sure that the structure is restored in the following sessions to continue to provide that sense of comfort to the client and to make sure he/she is still progressing in treatment.

      Reply

    • Taylor O'Rourke
      Feb 06, 2020 @ 13:34:57

      Hi Tim!

      I love how you mentioned that it is important for CBT to have structure since it is not a treatment modality that is intended to last for years like psychodynamic therapy would. This is not something that I had thought of previously! Not only does the structure help build that very important and crucial therapeutic alliance, but it also helps with structuring goals effectively and collaboratively with the client. In addition, the importance of structure relates back to the concept that yes, the therapist is the expert, but they cannot create change in the client all on their own. This is a team effort and does have a fairly strict time limit underlying it, so I think it was interesting that you brought that up. I think you also made a good point by saying that although CBT does stress this structure, it does not have to be perfect and rigid (as we do have the reputation for being heartless, rigid therapists) all the time; it can sway and fit the client’s needs at that time. Great post overall!

      Reply

    • Ashley Foster
      Feb 06, 2020 @ 14:56:37

      Hey Tim! You did a great job putting your own attitude in this post. The example of what therapy was and still is sometimes stereotyped made your post extremely enjoyable to read. I agree with everything in your post, especially the point you made in structure of timing in counseling, “ain’t got time for that”. If we want to be the most useful for our clients, we need to remember prioritizing. We must be the most beneficial for our clients if we want to help facilitate autonomy and success in their goal. Great job with the post!

      Reply

  12. Taylor O'Rourke
    Feb 06, 2020 @ 13:26:01

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

    The therapeutic relationship in CBT is one of the most important factors for promoting change in the client. Although the relationship is not the sole purpose of therapy like it is in other treatment modalities like psychodynamic, it still remains a large predictor of positive outcomes for the client. Throughout therapy, both the therapist and the client must be actively participating in order to work towards building a bond and achieving goals together. This is where collaborative empiricism comes in: it can be defined as an action-oriented relationship between therapist and client that has a strong research backing and works towards testing, integrating, and modifying the client’s thoughts and actions. Like mentioned previously, research has shown that the stronger the therapeutic relationship, the better the treatment outcomes for the client. This is all based off of early in the relationship and sessions, so it does matter right from the beginning. Although relationships can get better over time and recover from a rocky start, it is more beneficial to the client to have a strong bond with their therapist all the way through treatment. In order to build that bond with a client, there are non-specific as well as CBT-specific factors that therapists use. The non-specific factors, or Rogerian qualities, are things like empathy, unconditional positive regard, and genuineness that apply to therapy no matter what orientation is in use. There are also other non-specific factors, or interpersonal skills, like expertness and trustworthiness that a therapist must exude in order to establish a healthy relationship with their client. On the other hand, there are some factors specific to CBT that benefit the therapeutic relationship. Collaborative empiricism is one of the most important. The effectiveness of CBT relies on this quality because it is how the maladaptive cognitions/behaviors are identified and then tested to see if they truly have use. Some of the specific factors relating to collaborative empiricism are therapist-client activity level, client-specific factors, and conceptualization and treatment. Therapist-client activity level is important because unlike other treatment modalities, the client plays a very active role in therapy and does not just sit there receiving information from their therapist to make everything better. Expectations in CBT are that everything is a team effort; no one person is doing all the work, and the process is collaborative. Client-specific factors can include sociocultural factors, environmental stressors, and their presenting symptoms which should all be taken into consideration when forming the alliance. Lastly, conceptualization and treatment is a factor that is important because the more the client agrees with how their therapist has conceptualized their presenting concerns, the more likely they are to agree with any treatment goals or interventions the therapist may want to set up.

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

    It is important to have session structure for effective CBT because any of the skills that are useful for CBT are essentially useless if there is no structure to follow. In addition, most clients crave structure because they find comfort in it, so without it, there is no purpose to treatment anyway for them. Therapists can also use structure as a way of showing their expertness and trustworthiness which we already know are important non-specific factors for developing a strong therapeutic alliance. Not only is structure important for the client, but it is also important for the therapist. This is a good way of showing collaborative efforts and efficiency when the sessions can naturally flow from one to the next with the help of good structure. It is also important to note that the amount of structure for each session and each client will vary. Typically, early sessions have much more structure from the therapist compared to the later sessions when the client is more self-sufficient.

    Reply

    • Mariah Fraser
      Feb 09, 2020 @ 00:21:57

      Hi Taylor!

      I really liked how you incorporated all of the various concepts within your response to the first question. Everything about CBT is collaborative and clients are held at a higher standard in regards to putting in just as much work as their therapists, and they shouldn’t expect to sit there and be told what to do and how to manage their problems— after all they are the experts in their own lives! Additionally, much like a few other posts I read, having structure within sessions really seems like it would be beneficial and preferable to the clients because most people are uncomfortable with the unknown. Therefore, being informed prior to seems reasonable and necessary if a therapist hopes to build that foundation for a strong, positive therapeutic alliance. After all, how can a client trust you if they feel as though they’re being left in the dark!

      Reply

  13. Madison Armstrong
    Feb 07, 2020 @ 19:21:10

    (1) What is your understanding of the therapeutic relationship in CBT (include collaborative empiricism in your discussion)?
    The therapeutic relationship is the most crucial aspect of CBT. Without a therapeutic relationship there is no foundation for the therapy to be built off of and you would not see any progress with clients. If the client does not feel a connection to the therapist, then they are more likely to withdraw from therapy and not continue treatment. This relationship is the collaborative alliance to mutually work together toward the common goal of client change. This relationship is a working alliance where the therapist and client are mutually setting goals and working on interventions. Collaborative empiricism is defined as an action-oriented alliance that integrates, tests, and modifies a client’s thoughts, emotions, and behaviors. Through this relationship a client has a safe place to work on maladaptive thoughts emotions and behaviors and work on changing them to more adaptive ones. This leads to a reduction in the frequency and severity of symptoms and gives the client a higher quality of life. The key factors of collaborative empiricism are client-specific factors, conceptualization and treatment and therapist-client activity level. Therapist-client activity level is the time the therapist or client is taking an active role in treatment. In the beginning stages of treatment, the therapist takes on the teacher role and plays a more active role in therapy but towards the end of session the client is taking the more active role and starting to do more work on their own. Other qualities that are important for the therapeutic relationship include empathy, genuineness, expertness, and attractiveness.
    (2) Why is it important to have session structure for effective CBT?
    Session structure is important in CBT because it holds both the therapist and the client accountable for setting and working on goals. Since CBT is a time-limited therapy, it is important that the time that the therapist and client have together is being utilized to its maximum capacity. Having a structure can also provide the client with some relief because they know what the expectations are and what their time is being used for. Being able to review their homework and go over their mood and symptoms can provide the client with comfort because they are actively being engaged in the process. This structure also helps build on the therapeutic alliance showing the client their expertness in their profession. Personally, the idea of structure during therapy would make me feel more confident as a client that my goals were being worked towards and that there is hope for improvements.

    Reply

  14. Mariah Fraser
    Feb 09, 2020 @ 00:14:30

    Hi, Madison!

    I liked how you mentioned that structure within sessions holds the therapist and client accountable for setting and working towards their goals. It is so important for treatment to be as effective as possible within the short time they have together. Just as I like to have a syllabus accessible as a way to know what to expect for a course (it seems to reduce the anxiety of the unknown) I believe that clients must also have a sense of relief knowing that everything has been explained beforehand! And to your point, I agree that the client would likely feel more confident knowing that everything happening in the sessions has a purpose.

    Reply

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Adam M. Volungis, PhD, LMHC

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