Topic 3: Therapeutic Relationship & Session Structure {by 9/19}

There are multiple readings due this week (J. Beck – 3 chapters; Volungis – 2 chapters).  For this discussion, share at least two main thoughts: (1) What is your understanding of the therapeutic relationship in CBT (include collaborative empiricism in your discussion)?  (2) Why is it important to have session structure for effective CBT?  Your original post should be posted by the beginning of class 9/19.  Have your two replies posted no later than 9/21.  *Please remember to click the “reply” button when posting a reply.  This makes it easier for the reader to follow the blog postings.

24 Comments (+add yours?)

  1. Zacharie Duvarney
    Sep 17, 2019 @ 09:41:26

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

    The therapeutic alliance in CBT is unique given several key features. While common factors in the therapeutic relationship exist across therapeutic orientations, CBT is unique given its collaborative, directive, and empirical nature.
    A common misconception about CBT is that the therapeutic alliance is of little importance and is constituted by a cold and mechanistic relationship. This is far from the truth, as empirical data shows that a strong positive therapeutic alliance increases therapeutic gains. Thus, CBT clinicians seek to establish a strong rapport with their clients. There are common factors and CBT-specific factors that are associated with establishing the therapeutic alliance.
    Common factors are factors that are present in the therapeutic alliance across therapeutic modalities. One such example is Rogerian qualities. Carl Rogers established many practices for building a strong rapport with clients. Rogerian qualities emphasize a person-centered approach; treating the client with unconditional positive regard, dignity, and respect. One of the most important Rogerian qualities in CBT is empathy.
    Empathy involves being able to holistically understand and comprehend the position of another person. For the CBT clinician, this is extremely important, as not only does it strengthen the therapeutic alliance by validating the beliefs of the client, but it can also aid in identifying maladaptive behavior patterns, negative automatic thoughts, etc. Therefore, the expression of empathy is useful in that it builds rapport as well as aiding in conceptualization of the client.
    There are several distinct qualities of the therapeutic alliance within the context of CBT. The most crucial of these factors is collaborative empiricism. Collaborative empiricism is a multi-faceted concept. Essentially, it refers to the action-oriented nature of the therapeutic alliance where the client and therapist work together to participate in empirically validated interventions. Furthermore, this concept integrates objective measures and tests for the purpose of modifying behavioral and cognitive patterns. Thus, the phrase “collaborative empiricism” refers to the scientific, collaborative, and action-oriented nature of the therapeutic alliance. It is important to note collaboration in this context is especially important, as the end goal of therapy is for clients to be able to identify and modify maladaptive behaviors and cognitions independently. Reaching this goal won’t be possible without the client being an active participant in their own therapy.
    Volungis (2019) identifies three client-specific factors that influence collaborative empiricism: presenting symptoms, environmental stressors, and sociocultural factors. All are important to consider as they have various implications for both the therapeutic alliance and subsequent treatment.
    Presenting symptoms are important not only for providing a formal diagnosis, but also for conceptualizing the client accurately. Furthermore, therapists must be aware of their reactions to a client’s presenting symptoms. Being aware of your reactions to presenting symptoms is important in maintaining the therapeutic alliance. Verbal language and nonverbal behaviors can dramatically influence how the client feels during a session.
    Environmental stressors are important not only for identifying areas of treatment but also for maintaining the therapeutic alliance. Good therapists will take note of these events and discuss them with their clients. This not only conveys empathy, but also demonstrates to the client that you are paying close attention to them and listening to what they have to say. Following up about these events in later sessions can be very potent.
    Finally, socioeconomic factors influence the therapeutic relationship. Cultural awareness and competence are extremely important in regard to establishing the therapeutic alliance. Social norms are very different across cultures. Therapists should be aware of this not only for the sake of acting appropriately with their clients, but also so one does not label normal behaviors as maladaptive. Certain behaviors may seem maladaptive in one cultural context, and adaptive in another. For example, the differences between individualistic and collectivist cultures are stark. Other socioeconomic factors such as occupation, race, sex, and ethnicity are important to consider as well.
    All in all, the therapeutic alliance in CBT is one that is action-oriented and collaborative. Clients are expected to guide and participate in therapy by providing feedback, completing homework assignments, and learning skills for the purpose of problem-solving independently. The skills and interventions employed to achieve this goal are scientifically validated, which provides reassurance for clients and therapists alike. Furthermore, the therapist ensures the relationship does not become “mechanistic” by building rapport and practicing good interpersonal skills.

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

    There are many reasons why session structure is imperative to the effectiveness of CBT. Session structure yields many benefits for clinician and client alike. Volungis (2019) and Beck (2011) posit models for session structure that are very similar. Both models suggest sessions should begin with reviewing pertinent client information. It is unlikely any therapist can keep track of all pertinent information in their head; thus, it is important to review client notes before meeting with the client. Once the session begins, the therapist should conduct a mood check with their client. This will not only acclimate the therapist to the client’s current mood state but will also allow the clinician to track mood states over time. In doing so, one can analyze the improvement of a client between sessions.
    Following the mood check, the therapist should set an agenda for the session. This process should be collaborative. While there will likely be important issues to attend to from the last session, it is likely that the client has experienced significant events over the last week. Consequently, there may be a pressing matter that needs to be discussed. Furthermore, setting an agenda every week will normalize clients to the therapy process.
    Clients should provide updates after the agenda is set. Behavioral tracking is a crucial element of CBT, which facilitates frequent updates on client functioning. Getting updates from clients also helps bridge the gap between the previous session and the current session, making it easier to initiate conversation.
    Homework is an integral part of CBT, as it is a primary vehicle for client participation and self-monitoring. Given that homework is assigned every session, a review of homework is also warranted every session. By reviewing homework every session, the clinician and client can identify problem areas and tailor treatment to address these issues. Reviewing homework is essential in identifying negative automatic thoughts. Furthermore, homework is crucial in helping clients believe adaptive statements.
    After homework is reviewed, the therapist should prioritize the agenda. Now that the last week has been reviewed and pertinent matters have been identified, both the clinician and the client can be sure they are discussing the most important issues. CBT seeks to be quick and efficient, and by identifying what matters the client needs to work on most, time can be used effectively (which is very important given that sessions are often limited).
    Now that the agenda has been prioritized, the client and counselor begin addressing issues on the agenda. This involves conceptualizing the problem, identifying automatic thoughts and maladaptive behaviors, reducing client distress, deciding on behavioral change, implementing homework to facilitate behavioral change, and teaching the client skills necessary to achieve behavioral change. It is important to remember that by implementing this structure in every session, the client will become acclimated to the therapeutic process.
    The session should end with summary and feedback. This process is important for collaboration. By summarizing the session, you ensure that you have accurately conceptualized the client. If your summary is inaccurate, the client will help you to correct your inaccuracies. This is a potent method for building rapport and conveys professionalism and expertise to the client. Conveying that you are a confident and professional helps the client feel that therapy will be effective. By receiving feedback from your client, you will be able to tailor treatment plans to their needs. Again, clients are expected to be active participants in therapy, and providing feedback is one of the primary ways in which this can be achieved. Asking for feedback is also another effective method for establishing the therapeutic alliance.
    In summary, adhering to session structure normalizes the therapeutic process for clients, making it easier for them to participate in therapy and make positive behavioral changes. Structure helps the clinician stay organized, which facilitates accurate case conceptualization, as well as conveying professionalism and confidence to the client. Session structure can assist in building rapport with the client. Finally, session structure assures that therapy will end as quickly as possible, which saves the client time and money.

    Reply

    • Kelsey Finnegan
      Sep 17, 2019 @ 20:40:12

      Zacharie, I enjoyed reading your responses to this weeks questions. You did a very thorough job of explaining the therapeutic alliance in CBT. I like that you brought up the common misconception about the therapeutic alliance in CBT being cold and mechanical. Your response nicely refutes this misconception. The CBT therapeutic relationship still relies on non-specific/universal therapy factors such as interpersonal skills, genuineness, and unconditional positive regard.

      Also, your description of CBT session structure was specific and well done. I appreciate that you note the session structure normalizes the therapeutic process for patients because therapy can initially feel foreign and uncomfortable.

      Reply

  2. Kelsey Finnegan
    Sep 17, 2019 @ 20:19:01

    1.The therapeutic alliance in CBT differs from the therapeutic relationship in psychodynamic and humanistic therapies in several ways. Arguably, the most important component of the therapeutic alliance in CBT is the active participation of both the therapist and the client throughout therapy. The relationship is collaborative, rather than one-sided. Both the therapist and the client work together to set treatment goals for the client. CBT interventions are empirically based, but this does not mean that the client’s feedback is overlooked. The CBT therapist still adjusts their treatment approaches according to client input. The therapeutic alliance in CBT is referred to as collaborative empiricism, which is solutions focused and supported by research that is applied to client’s thoughts and behaviors.
    Both non-specific and CBT-specific factors are characteristic of the CBT therapeutic alliance. Non-specific factors refer to key counseling skills that are universal to most therapies and come naturally to most therapists. These include factors such as, empathy, unconditional positive regard, genuineness, interpersonal skills, trustworthiness, expertness, and attractiveness.
    Additionally, collaborative empiricism relies on CBT specific factors, which are key to the CBT therapeutic alliance. CBT specific factors include: therapist-client activity level, client-specific factors, and conceptualization and treatment. The therapist-client activity level will fluctuate over the course of therapy, but both the client and the therapists are active participants, which involves reciprocal collaboration. Client-specific factors broadly reference presenting symptoms, sociocultural influences, and environmental stressors. These are all important factors for the therapist to consider and be proactive about. CBT conceptualization and treatment involves a strong case formulation and synthesis of client information gained through formal and informal assessments.

    2.In order for CBT to be effective, it is important to have session structure for several reasons. First, most clients want and require structure because they are currently distressed and vulnerable. Structure is comforting, and it supplies clients with hope that therapy will be effective. Session structure also allows the therapist to demonstrate their knowledge (expertness), trustworthiness, and attractiveness to clients. Consistent session structure helps familiarize the client with CBT, and it provides direction. It also allows for collaboration because the therapist can set the plan for the session with the client and ask them for feedback and make adjustments accordingly. Finally, it improves organization and efficiency, which helps the focus to remain on the client’s problems and corresponding goals.

    Reply

    • Bianca Thomas
      Sep 18, 2019 @ 14:50:29

      Kelsey, I really enjoyed reading your thoughts on the therapeutic alliance! You showed that you had a clear understanding of what makes CBT different than the other therapy styles with your explanation of the collaborative process, and how it’s a team effort. You also demonstrated your understanding of how collaborative empiricism is directly related to the other factors of therapy including the non-specific, as well as client and therapist specific factors.

      Reply

    • Paola Gutierrez
      Sep 18, 2019 @ 20:13:27

      Kelsey — I appreciated your comment about how the client’s input is both valued and solicited in CBT even though it is solutions-focused and empirically based. Although some may interpret the evidence-based foundations of CBT as lending support of a view of CBT as a “cold/overly clinical” treatment, the CBT therapist truly cares about how clients are perceiving and experiencing the process of therapy. Your comment illustrates how client feedback is crucial for the collaborative empiricism in CBT that is needed for therapeutic change.

      Reply

    • Katrina Piangerelli
      Sep 18, 2019 @ 20:38:31

      Kelsey, I like the way you contrast CBT and psychodynamic and humanistic therapies. This shows your understanding of the therapeutic relationship within CBT, but also in psychodynamic and humanistic therapies. I think your description of collaborative empiricism really helped me further my understanding of this subject and the important material that you outlined. For the second question, you describe how to make CBT effective through session structure. I think that session structure is an essential part of CBT, and we share similar views about how this is an important part of CBT.

      Reply

    • Anthony Mastrocola
      Sep 20, 2019 @ 10:17:32

      Hi Kelsey,
      I really enjoyed reading your response. I agree with you that active participation by both parties is the most important component within the therapeutic alliance. I also appreciate your inclusion of client vulnerability in response to the need for therapy structuring. I agree that structure provides comfort for those that may feel hopeless.

      Reply

  3. Olivia Corfey
    Sep 18, 2019 @ 12:54:59

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

    The therapist-client relationship in CBT is distinctly collaborative in nature. The client and the therapist must agree to work together toward mutual goals in order to achieve them. To have a strong therapeutic relationship, the therapist must express some Rogerian qualities such as empathy, unconditional positive regard and genuineness. Collaborative empiricism is known as an action-oriented therapist-client alliance which is driven by research that integrates tests, and modifies clients’ thoughts and behaviors. More specifically to forming a working alliance, collaborative empiricism aims to identify maladaptive behaviors and cognitions in order to test their validity. While testing these cognitions and behaviors with the client, the client is able to have more adaptive cognitions and behaviors that are founded in reality. There are factors that contribute to collaborative empiricism: therapist-client activity level, client-specific factors, and conceptualization and treatment. The therapist-client activity level requires both the therapist and client to be present and active throughout treatment. Although, there will be lowered levels of therapists participation as sessions progress and the client is familiarized with CBT. This helps hold clients accountable for their own therapeutic progress. Client-specific factors include individually adapting therapy with the client’s specific personality traits, presenting problems and symptoms, sociocultural factors and environmental stressors. CBT is a highly structured therapeutic orientation, however, without individualization and modifications specific to the each client, there will be a lack of positive therapeutic outcomes. Lastly, conceptualizing cases with appropriate treatment goals requires formal and informal information provided by the client. Identifying the client’s strengths will be beneficial during the distress of identifying maladaptive cognitions and behaviors. The client and therapist’s agreement in the case formulation will aid in the activity levels and trusting the process of CBT. As clients may feel vulnerable within therapy, especially the first session, it is essential to treat clients how you would like to be treated if the roles were reversed. This is where the humanistic qualities of empathy, unconditional positive regard and genuineness come into play. While humanistic qualities are important, creating a working alliance requires collaborative empiricism.

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

    As CBT is a goal-oriented therapeutic orientation, it is essential to have structure throughout the sessions. Maintaining session structure provides organization and stability, and a way to progressively move towards treatment goals. Many clients lack stability in their daily lives, providing stability within the sessions may bring relief and room to focus on their well being. Collaborative session structure aids with the working alliance of the therapist-client relationship. Clients may feel more comfortable when they know what is occurring during the sessions. Clients will be more willing to participate in their own therapeutic progress if they are aware of what is expected from them and what to expect from the therapy sessions. The structure also socializes clients with the CBT orientation while demystifying what CBT sessions entail. This session structure is also flexible in order to address any immediate issues that may take priority of the session. The structure of sessions provides direction and purpose towards positive treatment outcomes.

    Reply

    • Bianca Thomas
      Sep 18, 2019 @ 15:00:12

      Olivia, your response made it clear you have a strong understanding of the therapeutic alliance and its relationship to collaborative empiricism. You did a great job of tying the topics together and explaining how their effectiveness is predicated on each other. I agree with your statement completely, that clients need to feel trusting of the process of CBT, and that it’s essential to treat clients how you would want to be treated if the roles were reversed.

      With regard to your response to session structure, I completely agree that the structure makes clients feel more comfortable and may make them more willing to participate in the process. I know for me, when I have my day to day written out, and I know exactly what I have to do, I feel a sense of certainty that I can see what’s ahead of me, and can check off items as I go down the list, making me feel more accomplished when it’s all done.

      Reply

    • Paola Gutierrez
      Sep 18, 2019 @ 20:22:01

      Liv — Your response was very thorough and demonstrates your strong understanding of the importance of the therapeutic relationship and session structure in CBT. I thought that the way you emphasized that having the basic counseling skills such as empathy, warmth, and genuineness allow the therapist to take perspectives of what it would be like to be in his/her client’s shoes. I also thought your explanation of the importance of session structure was helpful because it expanded upon the information in the readings. For example, you mentioned how a session structure may ease some anxiety in clients because they know what to expect in a session, as well as provide some (small) level of stability in their lives. I would personally feel frustrated and anxious if I were in a seemingly directionless therapy session, and structure would help me feel more guided and that progress was being made.

      Reply

    • Tricia Flores
      Sep 18, 2019 @ 23:38:54

      Olivia- I appreciated some of the points that you made that will help to enhance the therapeutic relationship and improve efficacy of treatment. Taking note of client strengths, which 1. would help the relationship and 2. assist in overcoming identified problems by utilizing those strengths. Another point you made that structure will alleviate concerns about what treatment entails and sometimes bring relief to clients who are lacking structure. Lastly, the idea of treatment clients as you wish to be treated is an important point. I know that even though it is a very basic concept, we, myself included, need to be reminded of this from time to time.

      Reply

    • Zacharie Duvarney
      Sep 19, 2019 @ 12:28:17

      Olivia,

      Overall, I thought your response was accurate and well-articulated. Our summaries of collaborative empiricism touched upon many of the same points. This made me feel more resolute in my understanding.

      Regarding your summary of session structure, I noticed you mentioned that clients may lack structure in their everyday lives, and that CBT session structure helps alleviate some of the distress clients may feel about this lack of structure. I thought this was a very insightful point.

      Reply

    • Anthony Mastrocola
      Sep 20, 2019 @ 10:23:26

      Hi Olivia,
      I think that it’s important that you mentioned how the Rogerian elements of empathy, genuineness, etc. set the foundation for the therapeutic alliance. The therapeutic alliance requires these Rogerian qualities in order to move forward towards action. I also liked how you tied the session structure piece back into its impact on the therapeutic alliance. I also believe that structure aids the therapeutic alliance, as clear expectations promote participation.

      Reply

  4. Bianca Thomas
    Sep 18, 2019 @ 14:45:35

    (1) What is your understanding of the therapeutic relationship in CBT (include collaborative empiricism in your discussion)?
    The therapeutic relationship is a process of collaborative empiricism where the client and the therapist form, as work together as a team in order to conduct therapy. Both of the participants (therapist and client) agree to work together towards mutual goals. It is optimal to have a strong positive therapeutic alliance because it improves the clients’ well-being, builds trust, and has positive impacts on the therapeutic process and outcomes. With regard to collaborative empiricism, action is taken by both the client and the therapist that integrates, tests and modifies the clients’ thoughts and behaviors throughout session. Many factors are part of the therapeutic alliance including empathy (understanding the client from their point of view), unconditional positive regard (warmth, acceptance and respect for clients), and genuineness (honesty and sincerity). Some interpersonal skills include expertness (evidence that the therapist demonstrates a certain level of specialized training, knowledge and expertise), trustworthiness (interest in the client’s welfare, being part of an established organization, an established reputation, optimism, instilling hope), and attractiveness (having unconditional positive regard, similarities between the client and therapist, “matching” the client). Some other more collaborative factors of the therapeutic relationship include the therapist-client activity level (both the client and therapist are engaged and working as a team), and client specific factors like their presenting symptoms, environmental factors and sociocultural factors.
    (2) Why is it important to have session structure for effective CBT?
    It’s important to have session structure for effective CBT because firstly, clients need and want structure, and this directionality allows the therapist to have a plan set in motion, as opposed to “typical” therapy where the client just speaks about the stressors over the past week. Structure from the first session instills hope as well as comfort that therapy may actually be effective in providing them some relief to their distress. Structure also emphasizes the therapist’s attractiveness, trustworthiness and expertness. Structure also socializes the client to CBT, including modeling how to approach and solve problems that relate to their distress. The structure also allows the therapist to model the collaborative function of CBT, providing guidance and direction for the therapist and the client as well as efficiency by staying focused on the most relevant problems and their related goals and interventions.

    Reply

    • Katrina Piangerelli
      Sep 18, 2019 @ 20:38:56

      Bianca, you and I described our understanding of the therapeutic relationship in CBT in similar ways. This included things such as the collaborative nature of the therapy and what benefits a positive therapeutic relationship has on the client. Beyond that, we also both described other factors such as empathy, unconditional positive regard, and genuineness as being important interpersonal skills. In the second question, you describe the structure of a session being important and effective in CBT. The emphasis is then placed on the attractiveness, trustworthiness, and expertness that is outlined in the first question. I think that we both share similar views on the importance of session structure in CBT and I agree with the way that you shared these thoughts.

      Reply

  5. Paola Gutierrez
    Sep 18, 2019 @ 20:03:23

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

    A common myth about CBT is that the therapeutic relationship is not valued in this treatment. Although researchers and practitioners of CBT argue that the therapeutic relationship alone is insufficient to produce change, CBT does not negate the impact that a strong therapeutic relationship has on treatment outcomes. Rather, CBT emphasizes a collaborative therapeutic alliance in which the therapist and client work together to achieve mutually agreed upon goals. Furthermore, CBT prioritizes active participation of both the therapist and the client. The client is expected to engage with the treatment both within session and outside of the session (i.e., by completing homework). I thought that the therapist eliciting feedback from the client about the session was especially powerful for building and maintaining a therapeutic relationship. The client is given an opportunity to share his/her thoughts about the session, including the bringing-up of any misunderstandings or concerns. Inviting the client to provide feedback not only builds rapport between therapist and client, but is an opportunity for the therapist to learn what is working well for a particular client and what may not be about the structure and nature of the therapy. Setting and prioritizing an agenda at the beginning of each session also gives the client an active role and voice in the therapeutic process; the client can clarify the most pressing problems he/she wants to address in the session and thus, the therapy session is focused on the client and his/her needs. As CBT is an evidence-based treatment, the therapeutic process of CBT itself is empirical, in which therapists and clients collaboratively experiment with, modify, and integrate clients’ thoughts and behaviors. This collaborative empiricism is the driving force behind therapeutic change in clients, as this process involves identifying maladaptive thoughts and then evaluating their validity. Collaborative empiricism incorporates an accurate conceptualization of the client and his/her problems; an honest conceptualization can also build the therapeutic relationship, as the client may feel that the therapist understands him/her. To summarize, the therapeutic relationship in CBT stresses active participation from both client and therapist throughout treatment in a collaboratively empirical process that results in change.

    2. Why is session structure important for effective CBT?

    Session structure is necessary for effective CBT because it provides direction for both the client and therapist. Without a consistent structure, treatment can become aimless and therapeutic interventions may not be effectively implemented (or may not even be addressed during the session). Clients often want a structure to sessions because structure can provide some relief from anxiety or distress about treatment. Furthermore, establishing and maintaining session structure shows the client that the therapist is competent in administering CBT; the therapist can smoothly guide the session in the appropriate direction(s). The structure of sessions in CBT are described as flexible and purposeful. CBT aims to address client’s distress and treat it as efficiently as possible. A session structure helps to alleviate clients distress as quickly as possible. Although some argue that CBT is too rigidly structured, CBT is flexible in that the structure is not set in stone; shifting the structure of the session in response to flow and client needs is perfectly acceptable as long as the session remains purposeful and helpful to the client. Session structure keeps treatment on track and provides guidance and direction to each session in the context of overall treatment.

    Reply

    • Tricia Flores
      Sep 18, 2019 @ 23:27:46

      Paola- I agree with the idea that there can be a flexibility to the structure of CBT sessions as long as they are purposeful and effective. I could see as a new therapist having difficulty managing this balance. I can relate it to when I was learning my current job and struggling to demonstrate effectiveness and professionalism while learning at the same time. I also agree that eliciting client feedback is a useful tool both for the client and for the therapist. Being open to that feedback and demonstrating the proper emotions when receiving it seems essential to the therapeutic relationship.

      Reply

    • Zacharie Duvarney
      Sep 19, 2019 @ 12:33:05

      Paola,

      As always your responses were comprehensive and well written. You and I both emphasized how the therapeutic alliance within CBT can be mistaken as cold and mechanistic. I firmly believe that having an action-oriented therapeutic alliance promotes rapport, and I can see through your response you do as well.

      Reply

  6. Katrina Piangerelli
    Sep 18, 2019 @ 20:44:16

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

    My understanding of the therapeutic relationship in CBT is that this is the foundation of therapy, where you build trust and rapport with clients. This positive alliance is correlated with treatment outcomes that are also positive. This is also true for a negative alliance that would result in negative treatment outcomes.
    The concept of “collaborative empiricism” is important to the therapeutic relationship in CBT. In this structure, the client and therapist work together to solve problems, working scientifically by theorizing and testing strategies in order to solve problems. In order to build a therapeutic relationship, it is important to collaboratively make decisions, seek feedback, vary your style, share your conceptualization, and share the treatment plan.
    Other ways to establish a good rapport would be to demonstrate good counseling skills and understanding of a client’s distress through empathic statements, tone of voice, facial expressions, and body language. All of these things can show a client that you are empathizing with them and that you understand where they are coming from. This will also demonstrate to the client that you view them as a valuable human being.
    The alliance between the therapist and client is also important when obtaining the desired treatment outcomes, which will result in an improvement in mental health and overall quality of life. Research has also indicated that relationship measures early in treatment were able to predict symptom improvement, which further supports the idea that rapport is vital to therapy. Rogerian qualities are important to practice as well, which include treating people with respect, dignity, empathy, unconditional positive regard, and genuineness. Interpersonal skills are important as well, and are demonstrated through expertness, trustworthiness, and attractiveness.

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

    CBT is very structured, setting the client and therapist up for success. The therapy session should begin before the client is actually there, with the therapist reviewing the client’s chart, including treatment goals, therapy notes, and homework assignments from previous sessions. What happens in the therapy session is specific to the client and is influenced by the clients symptoms, your conceptualization, how strong the therapeutic alliance is, the stage of treatment, and the problems on the agenda. These things can change a session, although each session can be outlined in the same general way.
    The first session is a little bit different than the following sessions. The goals of the first session are to establish rapport and trust with the client, normalize their difficulties, and instill hope. It is also important to guide clients into treatment by educating them about their disorder, the cognitive model, and the process of therapy. Next, you should collect additional data to help conceptualize the client, develop a goal list, and start solving a problem that is important to the client. The beginning of the session should be devoted to setting the agenda, doing a mood check, getting an update, and discussing the patient’s diagnosis along with psychoeducation. The middle part of the first session should be used to identify problems, set goals, educate the client about the cognitive model, and discuss a problem. When there are about five to ten minutes left of the session, you should end with a summary, review homework assignments, and elicit feedback from the client.
    After the first session, subsequent sessions are structured with the beginning being devoted to a mood check, setting the agenda, obtaining an update, reviewing homework, and prioritizing the agenda. The middle part of these sessions should consist of working on a specific problem and teaching cognitive behavior therapy skills in this context. The session should then consist of collaboratively setting homework assignments and then working on a second problem. The end of the session should be devoted to providing or eliciting a summary, reviewing the new homework assignment, and eliciting feedback. Structure allows the client to feel comfortable and hopeful that therapy will provide some relief to their distress. It also provides direction for both the therapist and the client.

    Reply

    • Olivia L Corfey
      Sep 21, 2019 @ 07:46:46

      Katrina,
      Your description of the therapeutic relationship is well depicted. I appreciated your integration of Rogerian qualities and collaborative empiricism with establishing a therapeutic alliance. Your second response shows your understanding of the therapeutic structure. I also agree that session structure can help the therapeutic alliance by providing stability. Overall, your responses were well written and helped further my understanding of the therapeutic alliance and session structure.

      Reply

  7. Anthony Mastrocola
    Sep 19, 2019 @ 10:56:31

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

    The therapeutic relationship is the rapport established by the therapist and client, consisting of warmth, trust, empathy, and unconditional positive regard. The therapeutic relationship begins at the onset of the first session. This is a critical stage where the therapist needs to create a welcoming environment that encourages the client to participate in their own therapeutic experience. A positive therapeutic relationship is almost completely necessary for fostering therapeutic gains. Without a positive therapeutic relationship, clients participate less and achieve less out of therapy. A strong therapeutic relationship makes for a successful therapeutic alliance in which both participants have clear objectives that they work towards and accomplish. The therapeutic alliance involves planned actions taken by the therapist and client toward specific goals.
    The empirical aspect of the collaborative alliance between both parties involves the interventions and assessments chosen, as well as the plans directing treatment. The treatment plans, interventions, and assessments are all defended by research. Everything that the therapist and client decide to do have been scientifically proven to be successful. This evidence-based concept of the therapeutic alliance found in CBT differs from practices found in other therapeutic orientations (e.g. psychoanalysis & client-centered). Psychoanalysis lacks empirical support for the common practices, and client-centered is based on the belief that a therapeutic relationship based on warmth is enough to foster positive therapeutic outcomes.

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

    Session structure is a critical aspect of CBT. In the most basic sense, structure is just a direction towards a specific goal. The client and therapist should both ultimately want decreased distress and an increase in functioning for the client. Structure ensures that both parties stay on track in-session, and increase the chances of accomplishing the specific goals previously indicated. Sessions should be structured to alleviate distress as quick as possible. The textbook also mentioned that most clients want and need structure, even if it may not seem that way. Clients may even learn how to structure their own lives through modeling clear agendas set through therapy. Clients entering therapy who feel hopeless and misunderstood may feel more hopeful if the therapist is able to provide a direction and plan for improving their condition. Clear transparent agendas may also alleviate anxiety for clients who are new to therapy and do not know what to expect. Session structure is not completely rigid, but is meant to be flexible and receptive to client needs. Structured therapy that can be flexible enough to adapt for changes in treatment is best for positive client outcomes.

    Reply

    • Kelsey Finnegan
      Sep 20, 2019 @ 19:57:08

      Anthony, your description of your understanding of the therapeutic relationship in CBT is similar to my own. I appreciate that you note the fact that clients will be more reluctant to participate in therapy and subsequently achieve less if the therapeutic relationship is not positive.

      Your response also provides strong support for the importance of session structure in CBT. I like that you note that “in the most basic sense structure is just a direction towards a specific goal.” I agree, and this is important because it is extremely difficult to achieve a specific goal without having some sort of structure in place. As a goal-oriented or solutions focused therapy, it makes sense that CBT is more structured than the psychoanalytic, insight-oriented therapies.

      Reply

    • Olivia L Corfey
      Sep 21, 2019 @ 08:22:54

      Anthony, your responses demonstrate your understanding of the therapeutic alliance and session structure well. I especially appreciated your emphasis on how the therapeutic alliance begins from the first time you meet the client. As for session structure, I agree that providing structure may provide relief from disorganization in one’s life. I thought your idea of how session structure could also be used as a tool for teaching new behavior through modeling was insightful.

      Reply

  8. Tricia Flores
    Sep 22, 2019 @ 19:56:05

    What is your understanding of the therapeutic relationship in CBT (include collaborative empiricism in your discussion)?
    Contrary to some beliefs, the therapeutic relationship in CBT is important and focused upon as an essential tool towards progress in treatment. In some treatments modalities such as psychoanalytic the relationship is heavily one-sided with the therapist leading the treatment from beginning to end. In CBT the therapeutic relationship is an alliance focused on collaborative empiricism, which is action-oriented and the treatment plan is based on research, utilizing tests with the goal of changing thoughts and behaviors.
    The therapeutic relationship is correlated with treatment outcomes in CBT and across other approaches. It can have a positive or negative impact on the client. In CBT a strong early therapeutic alliance is predictive of symptom improvement. Skills can be both modality specific and nonspecific. Nonspecific skills are used across most approaches. CBT specific skills are those that are used in the therapeutic alliance and are essential for collaborative empiricism.
    Non-specific skills include a broad range of skills including Rogerian qualities. Rogerian qualities include empathy, genuineness, and unconditional positive regard among others. Empathy is a tool that needs to be used with precision. Being too empathetic too soon or not soon enough and not being aware of how it is most likely being perceived by the client means that the relationship can be damaged. From a CBT perspective, empathy assists in identifying maladaptive behavior patterns, dysfunctional relational problems, negative core beliefs and automatic thoughts.
    In my current position I interview clients on a regular basis to determine program eligibility and made referrals to other programs. This is a non-clinical position in which unconditional positive regard and genuineness are useful in establishing a short-term relationship. Being genuine means that the client sees me as honest and sincere, which helps when I need to ask relatively personal questions and sometimes give bad news about benefit decreases. Unconditional positive regard means that I will be non-judgmental, warm, and not require the same of the other person. One example of the benefits of using unconditional positive regard in my position is that clients are more likely to disclose difficulties that he or she is having in completing our requirements due to disabilities, especially learning disabilities. They do not feel judged and feel less embarrassed to disclose this.
    In CBT these skills are utilized in a more sophisticated manner to develop the therapeutic alliance along with specific skills, which are needed to provide long-term treatment gains. As an example, unconditional positive regard increases disclosure to understand client history, thoughts, disruptive behaviors and other important information to direct treatment.
    Collaborative empiricism is a CBT specific skill, which is the most important skill to develop empirical effectiveness. The goal is to identify maladaptive behaviors and cognitions and then determine their validity. Another CBT specific skill is therapist-client activity level, which is collaborative. During the phase of therapy the relationship changes, in the early phase there is an educational relationship with the therapist being a teacher and the client being a student. In the middle phase there is a reciprocal collaboration with both having an active slightly equal relationship activity wise. At the later phase autonomy develops with the client becoming a protégé and the therapist becoming a mentor. There is no timeline for this progression.
    Therapeutic relationship development also have CBT specific client-specific factors including sociocultural factors, presenting symptoms, and environmental stressors. Sociocultural factors include being cognizant of unintentional biases and understanding that all people have biases. The most important step is understanding this and then working towards understanding and being cognizant when they present themselves. Presenting symptoms involve avoiding labeling clients and understanding that empathy is not certain in all client/therapist relationships. Developing empathy may require understanding perspective.
    Challenges to establishing a strong therapeutic alliance can be CBT specific. Examples of this include the expectation of providing feedback and autonomy during therapy. In therapist driven relationships client feedback might not be expected. The client developing an ability to provide feedback early in treatment with the therapist praising efforts will encourage further development of feedback resulting in improved therapy outcomes. Autonomy in treatment may be uncomfortable to clients, but is necessary so that when the client develops future issues he or she can utilize skills learned in treatment as opposed to needing to seek out treatment with every new stressor.

    Why is it important to have session structure for effective CBT?
    Structure in CBT has a number of benefits. Session structure is often desired by clients because of the comfort of consistency and direction it provides. It introduces clients to CBT and helps to develop a collaborative relationship. Without structure the most relevant problems may not be addressed. Going off on a tangent on a regular basis will now allow for the development of skills needed for autonomy. Structure does not mean that every session with every client looks the same or that there is never deviation, but it does mean that sessions generally progress in the same fashion.
    The stages of structured therapy include pre-session, early session, middle session, and late session. Pre-session is essential to review client information including past notes and taking time to have a formal assessment before the session to provide immediate feedback. Early session stage includes a check-in, mood and symptom check, setting an agenda, and reviewing homework. Setting an agenda takes away the mystery of what will happen and demonstrates some of the non-therapy specific factors of expertness, attractiveness, and trustworthiness. Middle session stage includes review problem, problem solving, feedback and summarizing. Late session stage includes summarizing session, assign homework, and final questions and feedback. The review of homework in the early stage and the assignment of homework in the late stage are essential to CBT. Without homework therapy does not extend outside of the meeting time. Assignment and review of homework shows consistency and the importance of working outside of session.

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Adam M. Volungis, PhD, LMHC

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