Topic 3: Therapeutic Relationship & Session Structure {by 9/22}

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 9/22.  Have your two replies posted no later than 9/24.  *Please remember to click the “reply” button when posting a reply.  This makes it easier for the reader to follow the blog postings.

41 Comments (+add yours?)

  1. Bekah Riley
    Sep 19, 2022 @ 15:02:52

    Establishing a therapeutic relationship with clients is a key component in determining treatment goals and outcomes. From my understanding, a therapeutic relationship in CBT is collaborative in the sense that both the therapist and client are active participants in therapy working to reach a mutual goal. In addition, throughout the therapeutic relationship, the therapist uses empirically supported interventions when working with the client. A term that captures both the collaborative alliance between the therapist and client as well as the importance of integrating effective research modalities that aid the therapist in testing and modifying a client’s thoughts and behaviors is collaborative empiricism. Collaborative empiricism encompasses both nonspecific and CBT-specific factors that contribute to a therapeutic relationship. Nonspecific or common factors are those that generally come naturally to therapists. These factors include Rogerian qualities such as being empathetic, having an unconditional positive regard towards the client, and being genuine in a therapy session. Various interpersonal skills such as expertness, trustworthiness and attractiveness are another common set of skills that contribute to the therapeutic relationship. CBT-specific factors on the other hand describe the skills implemented in therapy that are based more on empirically supported data around CBT. First off, the therapist-client activity level describes the alliance between a therapist and client as a team effort where the activity level will fluctuate as therapy continues. For example, in the beginning sessions of therapy, the therapist will generally have more activity by providing the client with psychoeducation. As therapy goes on, there becomes more of a reciprocal collaboration between the therapist and client, and as therapy comes to an end, the client’s activity is high and their ability to implement the skills learned in therapy on their own is apparent. Different client-specific factors such as their presenting symptoms, environmental stressors and sociocultural factors may also contribute to different CBT skills the therapist may use in therapy as well as the therapeutic relationship. Lastly, there is conceptualization and treatment where the therapist works with the client to gain information, synthesize that information into a case formalization, and then work collaboratively with the client to set and work towards treatment goals. This contributes greatly to the therapeutic relationship in the sense that if the client agrees with the case formulization, they are more likely to agree with and be motivated reach their treatment goals and participate in an intervention. Overall, both a collaborative alliance as well as empirically supported CBT contribute to a therapeutic relationship.

    Session structure is an essential element of effective CBT. Often times clients come into therapy in a very vulnerable state, and many aspects of their day-to-day life may not have much structure. A structured therapy session may help promote effective treatment in terms of collaborative goal setting and the implementation of meaningful interventions. In addition, when a therapist provides structured CBT sessions, it helps to build a sense of expertness and trustworthiness because it shows the client that the therapist is competent, and the client knows what to expect in terms of each session. Structured CBT sessions also increases the client’s familiarity with CBT, allows for a collaborative CBT nature, enhances therapeutic efficiency, and provides a direction both for the therapist in terms of implementing effective treatment, and the client in terms of their goals and potential treatment outcomes. An effective CBT structure for each session is broken down into four stages including the pre-session stage, the early session stage, the middle session stage, and the late session stage. In the pre-session stage, it is important to prepare by reviewing the client’s information in terms of their treatment plan and case formulization as well as any upcoming plans they may have discussed last session. In addition, providing the client with a formal assessment 5-10min before the session, if possible, may help further guide the session. Within the early session stage, it is important to check in with the client to potentially elicit a positive experience, assess the client’s mood and symptoms both informally and through formal assessments if necessary, set the agenda for the session in terms of the direction of therapy, and review homework from the previous session. The middle session stage is where the client’s specific problem is reviewed, and problem-solving strategies are implemented using CBT. In this stage, it may also be important to provide the client with feedback and summarize various strategies learned in session. Lastly is the late session stage where the session is summarized in terms of common theses and CBT models. Based on the common themes of the session, a homework assignment is then given for next session so the client is able to implement the skills learned in therapy on their own. Any additional questions or feedback in terms of what’s working for the client or what can help to improve the client’s therapeutic experience are also discussed in the late session stage. Although it is important to be flexible when the session structure does not go to plan or the client has other needs that need to be attended to, it is important to have a plan and generally strive to implement that plan throughout each session in order to most effectively help the client work towards reaching their treatment goals.

    Reply

    • Yoana Catano
      Sep 21, 2022 @ 14:12:08

      Hi Bekah, it is interesting how you summarize the collaborative empiricism. Both, therapist and client work actively towards a mutual goal, using empirically supported interventions to modify client thoughts and behaviors. Also, you put emphasis in the motivation that the client gets derived from the collaborative work, and the way it acts in favor of the achievement of the therapeutic goals. Thanks for the insight. For the second question, I like to read that structure is important for the clients’ life since they could come with no much structure. Structure in general provides directions for client and therapist, it also can be flexible if some adjustments or modifications are needed. I will add that everything that happens outside the sessions is as important as what happens inside the session, this includes reviewing the case prior and homework.

      Reply

  2. NikkiAnn Ryan
    Sep 19, 2022 @ 17:34:39

    The therapeutic relationship is essential to the effectiveness of treatment, including CBT. A positive relationship helps clients feel respected, understood, and safe to express some of their most sensitive, vulnerable thoughts, emotions, and experiences. Without a sound therapeutic relationship, clients may not feel comfortable exploring such thoughts and experiences and may, therefore, not effectively work through their issues. Whereas a positive therapeutic alliance is correlated with positive treatment outcomes. A strong therapeutic alliance is beneficial for other important therapeutic processes such as repairing ruptures in the relationship and helping generalize the therapeutic relationship to the client’s other relationships. For instance, counselors with a positive therapeutic alliance may feel that the relationship is strong enough to draw the client’s attention to the way they interact with the counselor and compare it to their other relationships. The counselor can then use the relationship to help clients in the context of their other relationships. It is important to note that CBT is a collaborative process. Collaborative empiricism is essential for identifying maladaptive thoughts and behaviors and checking for their accuracy and/or usefulness. Together, the client and counselor develop hypotheses and then test them to find the evidence for and against the accuracy of the thoughts. Basic counseling skills including empathy, genuineness, unconditional positive regard, and trust are imperative for collaborative empiricism. The specific factors of collaborative empiricism are: (1) the therapist-client activity level, specifically, CBT requires highly active sessions for effectiveness, (2) client-specific factors, such as their presenting symptoms and relevant environmental stressors, and (3) conceptualization and treatment which includes an accurate case formulation and agreement between the client and counselor regarding the treatment goals. Ultimately, these factors contribute to the development of more adaptive thoughts and behaviors and a decrease in distress. I think that Beck’s idea for counselors to write a card with several points about establishing and maintaining a therapeutic alliance and reading it before every therapy session is great and can aid in developing a positive therapeutic relationship with clients. I can see myself implementing this strategy as a counselor as a way to get into the frame of mind of promoting a positive relationship before each session. Similarly, I like the idea of creating a specific card for clients that I may have a negative reaction to so that I can keep my expectations for myself and my client in check. I believe this will help keep sessions productive and assist in building and maintaining a good therapeutic relationship.

    Session structure is important for remaining productive during the small window of time clients and counselors have together and is essential for effective CBT. By structuring sessions, clients and counselors can make sure that they prioritize the most important topics during the session time. Prioritizing is crucial because it ensures that clients are getting to cover the topics that are most important to them, but it also allows the counselor to plan to discuss the most distressing topics first so that the client has time to de-escalate and not leave the session feeling overly distressed. It also helps to secure time to review their homework or action plan for the previous week and the coming week to make sure that clients are enhancing their skills outside of sessions. This also helps to demonstrate that the counselor knows what they are doing which connects to the concept of expertness, a key component of rapport building. Additionally, session structure bridges what is covered and learned from week to week and provides a valuable opportunity to begin planning for the next session so that both the client and counselor are prepared, which promotes future productive sessions. Ultimately, session structure is a key feature of effective CBT. It helps with staying on track with the treatment plan, making progress towards goals, and, overall, it ensures that clients are getting the most out of their treatment.

    Reply

    • Ashley Torres
      Sep 21, 2022 @ 12:44:42

      Hi NikkiAnn, your response was clear and effective. I enjoyed how you said a strong therapeutic alliance can be strong enough to draw the clients attention to the way they interact with the counselor. That is a great strategy to use because it may reflect how the client interacts with other individuals outside of the therapy sessions. It takes a strong relationship for the therapist to openly point out their behavior and use it to address issues or maladaptive thoughts.

      Reply

    • Tuyen Phung
      Sep 23, 2022 @ 21:10:30

      Hi NikkiAnn,
      You give me a new insight into how the therapeutic relationship is important for the effectiveness of treatment by the way clients use therapeutic relationships in the context of other relationships. Actually, I think that counselors are the people from whom clients can easily receive unconditional positive regard. People can have a negative about themselves because of reflecting the view other people have about them. Therefore, counselors can help the clients feel accepted, leading to their feeling of being accepted by others. Also, I like your emphasis on prioritized issues in the session structure. I usually wonder how clients feel between sessions when they leave the previous session without dealing with their problems, even if their feeling gets worse at the end of the session. With said that, session structure can be helpful in preventing both counselors and clients from leaving therapy with disturbing feelings.

      Reply

  3. Amanda Bara
    Sep 19, 2022 @ 18:40:43

    The therapeutic relationship is critical for CBT as it allows clients and therapists to work together towards goals and it facilitates deep discussions. Collaborative empiricism is the idea that both the therapist and client are working to foster growth, change and an overall better quality of life for the client. Both the therapist and client have to be active in the sense that they are being open and honest with each other about how therapy is going. Being collaborative means that through the relationship both individuals are establishing meaningful goals, positively reinforcing for positive changes and reaching for the bigger picture. At the beginning of therapy, the therapist acts as more of a teacher in helping the client gain knowledge about their thoughts, behaviors, and emotions. The client acts as a student in being receptive to this information and insight in order to establish meaningful change. As sessions progress, the relationship becomes more of a mentor-protegee dynamic where the client is enacting the skills and interventions by themselves in order to better themselves on their own. The relationship dynamic between therapist and client is so important and establishing rapport especially in the beginning stages is crucial. In order to dive deep into one’s personal life and struggles there needs to be a certain level of trust that is built between two individuals. Because the approach of CBT is based on empirically supported data and research the term collaborative empiricism proves to be a highlight of this therapy. CBT requires active participants and work in order to create positive change and growth. Without the alliance of a therapist and client there may not be any significant progress through therapy.

    Session structure is a fundamental aspect of cognitive behavioral therapy as it helps to align treatment goals in the short time that therapy is implemented. Structure allows therapists to manage the most prominent and essential problems that a client is dealing with in a timely manner. By setting an agenda and highlighting the main concerns for each session, there is room to also address the client’s well-being, medication adherence and homework review. Going over homework is important as it helps to incorporate what is going on inside the therapy session to the client’s everyday life. If clients are not keeping up with their tasks outside of therapy then that is something that needs to be addressed in session. Structure also allows for the therapist and client to go over any concerns regarding the therapy itself which is an important part of building rapport for CBT to work effectively. Without the agenda and planned out session there may be no actual initiation and intervention work done. It is important that clients can bring up their problems and concerns but there also needs to be an end goal or bigger picture that the client is working towards. Structured sessions allow for treatment plans to be incorporated and diagnoses to be coped with in appropriate ways.

    Reply

    • Bekah Riley
      Sep 20, 2022 @ 15:33:41

      Hi Amanda,
      I really enjoyed reading your response this week! I thought you did a great job of describing collaborative empiricism by highlighting that both the client and therapist are active participants in fostering growth and change so that the client is able to have a better quality of life overall. In addition, I really liked how you mentioned the importance of trust in a therapeutic relationship because often times when there is a foundation of trust, clients are able to open up about things that they may have been holding internally, sometimes for years or longer. I also really liked how you emphasized the importance of structured sessions in CBT and how they allow the therapist and client to focus on problems that are the most relevant. Having structure in CBT allows the therapist and client to collaboratively work towards meaningful goals!
      Overall, great response!

      Reply

    • Tom Mandozzi
      Sep 22, 2022 @ 14:48:02

      Hi Amanda,

      I really liked how you mentioned the “end goal” or “bigger picture” as an important aspect to consider when engaging a client in CBT interventions. Sometimes it is so important in therapeutic work, and in any other setting really, to take a step back and be mindful of what the broad picture looks like and what the ultimate goal and reason for treatment is. It can get repetitive and lack direction when we just look at one session but finding a balance between looking at the immediate future and the bigger picture is so important. Great perspective!

      Reply

  4. Patricia Ortiz
    Sep 20, 2022 @ 10:44:05

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

    In CBT the therapeutic relationship should be cooperative and there should be an effort of mutual collaboration to solve the client’s problem. Also, it is active and logical; the therapists act with a safe therapeutic attitude and as a model and reinforcer. In CBT the therapeutic relationship is also the framework in which the client’s learning processes are developed and behavioral techniques are implemented.
    There are several factors that influence the consolidation of a good therapeutic relationship. For example, Carl Rogers highlights three basic elements for creating a therapeutic bond that depends directly on the therapist: empathy, unconditional acceptance, and authenticity or congruence. An important factor for the success of therapy is the attitude of the therapist himself. For example, being empathetic, active listening, and confident in the client’s potential to change and improve. Also, I think it is important that the clinician has the ability to see the client as a whole.
    Another important aspect that the therapist and the client must agree on is the homework to be accomplished in CBT therapy. Often, the client has expectations about therapy that are far from reality (or from what the therapist wants to do), such as the idea that things will change just by attending therapy sessions. Not only must the tasks be appropriate to the client and his problems, but the client also has to understand what they have to do and why they do it since, after all, they are their own agent of change.
    Also, I believe therapists should be close to the client, on the contrary, distant and cold attitudes make the CBT process difficult. One crucial factor is that the clinician has awareness of their own limits and ability to refer, if necessary, due to the fact that rescuer attitudes help the client very little.
    On the other hand, collaborative empiricism is a method of psychotherapy in which the client and the therapist collaborate on problems and promote change via respect, understanding, and communication. Undoubtedly, the therapist constitutes a model of special relevance for his clients, in this sense, it is that they must pay special attention to their own behavior. Thus, for example, if a client wishes to stop smoking, the therapist should not smoke in front of them; If they have self-organization difficulties, the therapist should not attend to them with significant delays or cancel consultations with them with little anticipation. Finally, the behavior of the therapist must be consistent with what they preach during the course of treatment.

    In conclusion, I believe that a therapeutic relationship in CBT is one where the therapist does not act as the savior of anyone but can accompany humility and genuine interest in their client’s potential. The therapist is not a friend, nor someone who advises their clients. A healthy therapeutic relationship is one where therapists work at the service of the client and it is important that the roles of both are clear. In CBT it is also important that the therapeutic relationship takes place in the “here and now”, in the present moment, that the therapist can help the client to uncover their cognitive and emotional experiences, recover from contact with their emotions and behaviors, in addition to accompanying the clients to accept and express them in a healthy way. Also, managing the relationship with the client is revealed as a key point in the therapeutic process. It must be accompanied, naturally, by the knowledge of the theoretical paradigms and the technical procedures of the approach. The integration of both elements, that is, the selection of scientifically validated techniques but applied in the context of a well-conducted human bond, will enhance the horizon of possibilities of Cognitive Behavioral Therapy.

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

    In Cognitive Behavioral Therapy, we focus on solving the person’s current problems, and the reasons that afflict them today and make them suffer. In some cases, when necessary to understand the current problem, we ask for information about the past; but the accent of the treatment is placed on solving today’s difficulties; this is why the dialogues between the client and the therapist are guided by practical goals. It is not at all a spontaneous talk without direction, but rather we are guided by the reasons that brought the client to treatment. Because of that, every session should have a structure for it to be effective. We should always keep track of the client’s accomplishments and milestones.
    Also, it is important that the client feels understood, that they feel that the objectives have to do with them, and with their current and present state. If the patient does not get involved with the treatment, nor does they have any interest in changing, it will be difficult for the treatment to go ahead. Therefore, the therapist will have to, during the first sessions, carry out a good interview that helps the client to see what things they want to change in their life and what things they want to keep the same. Likewise, the client has to feel confident enough to open up to the therapist, feel respected, and not be judged. Feeling that the psychotherapy space is a safe place where they can gradually show themselves as they are without the danger of being attacked or judged.

    Reply

    • Bekah Riley
      Sep 20, 2022 @ 15:44:10

      Hi Patricia,
      I thought you had a great response this week! I really enjoyed how you emphasized the importance of a collaborative therapeutic relationship in CBT! I thought you did a great job of explaining Carl Rogers’ three elements important in forming a therapeutic bond and how the attitude of a therapist can help to determine the strength of the therapeutic relationship. I also enjoyed how you mentioned that a therapist should be consistent with modeling appropriate behaviors such as showing up on time, being prepared for each session, and minimizing cancelations if possible. This will make it easier for the client to feel confident that they can rely on their therapist to be attentive and willing to collaborate to work on goals each session!
      Overall, great response!

      Reply

    • Ashley Torres
      Sep 21, 2022 @ 12:34:22

      Hi Patricia, your response was very well informative! I really liked how you talked about homework in CBT and its importance. Not everyone knows what therapy consists of and often people think attending sessions will automatically get rid of their problems. Homework needs to be assigned because in a session the client and the therapist work together on goals and plans. If the client is not putting in effort outside of therapy, then they will heavily rely on the therapist when they are in distress. The therapist also needs to revisit the homework the following session in order to determine if it is effective.

      Reply

    • Tom Mandozzi
      Sep 22, 2022 @ 14:43:47

      Hi Patricia,

      I really resonated with what you said about ensuring that sessions and the treatment process is guided by the reasons and presenting concerns that brought the client into treatment instead of engaging in more spontaneous or random talk with the client. It can be so easy to get off topic when speaking with friends or someone you know in your personal life, but it is critical to remember that in order to professionally conduct CBT therapy, every session should be structured and planned. I also agree that client’s milestones and accomplishments should be tracked and monitored as well to assess for progress and to support motivation toward continued engagement in treatment. Great point!

      Reply

    • Rylee L Ferguson
      Sep 24, 2022 @ 14:42:06

      Hi Patricia. I liked how your post walked through the importance of homework in CBT and how meeting together is not enough to see real change. This is unlike other theory’s where the real work is only done in the presence of the therapist. I think having homework throughout the process helps instill the idea that growth, though fostered by the therapist, is ultimately in the hands of the client. It also gradually prepares them for handling the world on their own after the relationship is terminated.

      Reply

  5. Ashley Torres
    Sep 21, 2022 @ 12:25:47

    Collaborative empiricism is a therapeutic method that has a heavy focus on a client’s actions and behaviors. Collaborative empiricism is effective with a lot of individuals because it is driven by research that integrates, tests, and modifies clients’ thoughts and behaviors. Collaborative empiricism includes a therapeutic alliance which consists of the client and therapist working together as partners to address issues and action plans. CBT believes the therapeutic alliance is essential but shouldn’t be heavily relied on for change. The alliance is important because it shows the client that the therapist is invested in their role and in the client. For example, a therapist needs to be empathetic, have unconditional positive regard, and be genuine during sessions. Before the client-relationship gets started, the therapist will inform the client of CBT and how they will work together to reach their goals. Then the client will try interventions and share with the therapist their experience. The therapeutic relationship then must come into play in order for the client to share vulnerable information and the ability for the therapist to challenge the client without offending them. I believe the therapeutic alliance is very important in CBT because if a client does not feel safe or comfortable around a therapist, they will not be able to take advantage of all that CBT therapy offers.

    In CBT session structure is important because it helps manage time and priorities in a session. Clients have limited time with their therapist therefore it is crucial to have an agenda and constantly be working towards their current health. This will help the client work towards goals that will help an issue overall and not just scraping the surface. The therapist will work with the client in discussing what issues should be talked about first due to sensitivity. It would not be healthy for a client to break down the last five minutes of sessions and not have time to take breathers and relax. Session structures are also crucial because feedback and homework is an important component to growth. If the client is not working on the skills outside of session it is going to be difficult for them to become independent. Feedback is also needed because the therapist needs to be aware of what is working and what the client believes could change to maximize their time during the session.

    Reply

    • Yoana Catano
      Sep 21, 2022 @ 23:32:52

      Hi Ashley, I agree that with a good therapeutic alliance, the client could benefit a lot more from CBT, even when a Therapeutic relationship shouldn’t be the only factor to change. Also, I really like the concept of homework, since is the way for them to put in practice what they have learnt in therapy, and as you said, this is a way to train independency as the last step in the therapeutic process.

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    • Tayler Shea
      Sep 23, 2022 @ 20:08:46

      Hi Ashley! I really like how you started off by stating that collaborative empiricism is driven by research. I think that is a really important topic to talk about. I also like how you noted that a therapeutic relationship is important but not the main ingredient when working on changing behaviors. I also like how you noted that the session structure can play a valuable role in setting the agenda which also can influence trust and the therapeutic relationship. I like how you pointed out that we should organize our agendas based on sensitivity level. I agree, it would be awful to leave a client in distress!

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    • Patricia Ortiz
      Sep 23, 2022 @ 20:19:31

      Hi Ashley!
      I agree with you that the therapist should inform the client of CBT and how they will work together to reach their goals; then the client will try interventions and share with the therapist their experience. This feedback is critical because we will know if the client has an interest in continuing with therapy. The client’s expectations are developed through interaction with the therapist but also from all those elements present in the consultation. In this way, generating a space that can favor the development of positive client expectations can increase their motivation with the intervention.

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  6. Yoana Catano
    Sep 21, 2022 @ 12:59:12

    (1) It is important for everyone to feel treated well when looking for a service, the first experience with a lawyer, a doctor or even at a coffee shop, will mark down our level of satisfaction with the service received. Now, when attending therapy, it is equally important to feel comfortable, but it will require more from the relationship; the client is going to expose fears, sadness, traumas and problems in general that could have been hidden from the rest of the world, in the eyes of a client, this is a big step, not only selecting a therapist, but attending the first session, and deciding to return.
    On the other hand, as a therapist, I should understand that my knowledge won’t be enough if the client does not trust me. In this case, to be able to get the best results, I need to work on building a positive therapeutic relationship.
    The humanistic approach in psychology opened up the vision to the human potential in therapy, making emphasis in the need to approach the client with respect and also other factors like empathy, unconditional positive regard, genuineness, expertness, trustworthiness, attractiveness (Volungis, 2018). These elements are necessary in working with individuals and obtaining desired outcomes, as mentioned in Beck (2021) the therapist’s objective is to make clients feel safe, respected, understood, and cared for.
    But those factors are not considered the only ones responsible for treatment outcome, there are specific factors in CBT that are necessary to establish an effective relationship in a collaborative empiricism (Volungis, 2018). This means that, in therapy the working alliance shares responsibility between client and therapist. This activity is not always 50-50, it varies according to the phase of the treatment, initially it is more responsibility on the therapist to educate, and train the techniques to the client, at the end is more responsibility on the client to demonstrate skills to regulate their functionality autonomously.
    This working alliance also requires the therapist’s self-awareness of the response they give to specific client factors, including reactions to specific diagnoses, lack of empathy, influence of life events, legal or medical problems and sociocultural factors (Volungis, 2018). If any of these concerns are identified and are affecting the collaborative practice, they can be solved through supervision, training or even therapeutic resources. CBT requires the therapist to be active in the process, not only by providing psychoeducation, but also by recognizing their role in the collaborative relationship.
    A collaborative empiricism also helps the client to navigate different difficulties throughout the treatment, being able to obtain valuable information, conceptualize their problem, strengths, progress and stagnation. Those counseling skills that are based on an effective relationship, constitute the rationale for the therapeutic change and thus, the achievement of the goals.
    Finally, the therapeutic relationship is also a good way to role play other relationships in the community, the client will learn how to communicate effectively and how to manage emotions better based also in the collaborative relationship.

    (2) If you don’t know where you are going, how do you know if you have arrived? If we think about the eternal process of therapy that was presented in psychoanalysis, we conclude that we need structure. Structure facilitates the view of an “end” in therapy. As mentioned in the question above, the selection of a therapist can include costs and time. A client that enters therapy, would like to know for how long they will be attending, and even when this is not a question that can be easily answered, a structured process will also guide the time and cost that a therapeutic process carries.
    Furthermore, structure also provides efficiency. The organization facilitates working on the most relevant problems with the corresponding goals and interventions. Dividing the session into pre-session, early, middle and late sessions, provides guidance to both client and therapist, ensuring that there is a purpose on each step (Volungis, 2018). The main benefits from structure, are related to the preparation before the session. A good CBT therapist should have some knowledge about the client, the past session, or some updates before starting. It shows respect and expertness.
    CBT also utilizes homework that provides elements for the client’s autonomy in managing their own thoughts and emotions; the feedback is an encouraging element that means the process is active, if well done by the therapist, it can be powerful in the client self-awareness; and the structure empowers the client in managing their own treatment/recovery, with flexibility in adjusting sessions.
    At the same time, structure provides the ability to compare, it means, the possibility to measure the intervention and associate it to others, in order to discover new knowledge in psychology. For example, consistent structured interventions have brought the estimated time for treating depression vs treating ADHD, or the effectiveness of using certain therapeutic goals when treating anxiety.
    References
    Beck, J. S. (2021). Cognitive therapy: Basics and beyond (3rd ed.). Guilford.
    Volungis, A. M. (2018). Cognitive-behavioral therapy: Theory into practice. Rowman & Littlefield.

    Reply

    • Rylee L Ferguson
      Sep 24, 2022 @ 14:46:59

      Yoana, I really loved the opening line to your discussion on in the importance of structure. It was a poetic way to sum up one way structure is integral to CBT actually being implemented correctly. You also mentioned that structure aids efficiency in this process. I think this is true, but needs to balanced out with flexibility. We cannot rush through sessions in the name of meeting all the agenda items for the day. When unexpected things come up in session it is important to address them even if it costs time that was originally dedicated to another topic. With both flexibility and structure, CBT can be effective and efficient timewise.

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  7. Rylee L Ferguson
    Sep 21, 2022 @ 20:08:10

    My understanding of the therapeutic relationship in CBT is that it partly draws from previous approaches well incorporating new and evidence based components. Like in Roger’s humanistic approach, CBT values features like empathy, unconditional positive regard, and genuineness. When a therapist embodies these aspects a client feels more comfortable exploring deeper and more personal content that is important to cover in order to move forward. Additionally, the therapeutic relationship involves establishing trustworthiness, expertness, and attractiveness, all of which were previously highlighted by Strong and work to give the client confidence in their therapist. Collaborative empiricism seems to be what sets apart the therapeutic relationship in CBT. The collaborative component means that the work is in the hands of both the client and therapist. Both have to be on board in order to create positive change. The empirical aspect means using evidence based techniques to test the adaptability of notions the client has or believes. In this way the client needs to be open and honest in bringing forward private information, while the therapist needs to be well-informed on the best treatment techniques according to research. I think this unique aspect of the therapeutic relationship in CBT should be more often highlighted in discussion of its benefits. The collaborative nature implies that people have power over their own situation while also ensuring that they do not have to figure out how to heal alone. This seems both empowering and comforting.

    The structure of a session may differ depending on the specifics of goals and needs each client has. However, it is important that each session still be structured for a number of reasons. Firstly, it is important to have structure to ensure that each part of the agenda gets covered. If therapists were to have unstructured interview style sessions then the topic may deviate from what is actually important and relevant to treatment. The structure ensures that an appropriate amount of time is spent on things like checking on mood, on progress or problems with treatment plans, and on feedback. The structure also ensures that the treatment process is actually moving in an intentional direction. The structure allows time for working on and discussing skills that help move towards established treatment goals. Without working on intentional steps there is no way to guarantee progress is made, and by the end of therapy one might discover no improvement has been made. That being said, it is important that the session structure be flexible in CBT. In the initial phases of treatment a therapist might have an idea for what future sessions will involve and the skills they want to teach the client. However, at some point the client may reveal some novel information that might make it worthwhile to alter the original plan. For instance, during a session a therapist might have planned to work on cognitive restructuring but the client admits to having experienced something traumatic during the check-in. This would be a sign for the therapist to deviate from the structure and allocate some time to focus on this intense new revelation.

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    • NikkiAnn Ryan
      Sep 21, 2022 @ 22:13:16

      Hi Rylee,

      I really liked your description of collaborative empiricism and the importance of the therapeutic relationship. I absolutely agree with your statement about how the collaborative nature of the therapeutic relationship seems both empowering and comforting. I think that is a really great and insightful point. It is also probably accurate for a lot of people pursuing therapy. It must be reassuring for them to process some of their problems/concerns with another person while also building skills, independence, and confidence to problem solve on their own.

      Reply

    • Patricia Ortiz
      Sep 23, 2022 @ 20:29:28

      Hi Rylee,
      I agree with you that the structure of a session may differ depending on the specific goals and needs each client has. It is essential to assess each client individually and analyze the seriousness of the problem, the variables of the person, the context, culture, etc. Each case is unique, and the treatment should likewise be personalized. Some techniques might work better on some clients and some techniques may need a little more time to work on some clients too and that is fine as long as everything is communicated and the client is committed and motivated to change!

      Reply

  8. Tuyen Phung
    Sep 21, 2022 @ 21:25:20

    A therapeutic relationship is important in building effective therapy with clients regardless of any approach. CBT uses many similar factors such as empathy, genuineness, unconditional positive regards, trustworthiness, expertness, and attractiveness. However, CBT has some remarkable factors in a therapeutic relationship that should be concerned. Most importantly, collaborative factors are important in CBT. At the therapist-client level, unlike other approaches in which clients play a passive role and therapists play a role as teachers and doctors during therapeutic sessions, clients in CBT therapy play an active role in which they engage throughout the therapy. Also, clients are expected to monitor their changes without much therapy intervention. Therefore, the changes in clients come from therapist-client effort working in a team. When clients can build their autonomy, the role of therapists becomes minimal and gradually terminates. Specifically, in the early phase of therapy, therapists guide the conversation and clients may be pretty passive as their activity is low. Psychoeducation can be used at the beginning of therapy. However, therapists’ activities may decrease while their clients’ activities increase. In the middle phase, techniques of CBT work effectively and reciprocal collaboration is necessary. Finally, when clients become active and manage their own problem-solving. Therapists can withdraw step by step.
    The session structure is typically used in CBT. It is important to have a session structure for effective CBT for several reasons. First, consistent structure helps to socialize clients to CBT. It also promotes collaboration between therapist and clients during sessions, not only one directional intervention from therapists. In addition, session structure strengthens therapeutic efficiency by building organized therapy that focuses on the problems of clients. Moreover, when therapists have a session structure, it is a useful way to manage the time and engagement of clients in the session. As human beings, therapists can be easily “guided” by clients with unimportant stories if they do not have a session structure. When working under managed care, session structure is a great source to demonstrate the working expertise of therapists. However, the session structure should be flexible to adapt to unexpected issues coming from clients after each session.

    Reply

    • NikkiAnn Ryan
      Sep 21, 2022 @ 22:04:03

      Hi Tuyen,

      I enjoyed reading your post. I like that you thoroughly described the process in which the therapist’s activity level is higher in the beginning, when there is more guidance and psychoeducation, and then decreases throughout the course of treatment while the clients are gaining more autonomy and increasing their activity level. It seems like this is a concept that is pretty unique to CBT. I am looking forward to working with clients and seeing this progression in client autonomy as they go through treatment!

      Reply

  9. Tom Mandozzi
    Sep 22, 2022 @ 01:23:49

    Establishing a strong therapeutic relationship is critical in effectively implementing CBT. A strong rapport and therapeutic alliance between the client and clinician is necessary for a collaborative approach to treatment and the development of goals that are realistic and attainable throughout services. The client and clinician are both active participants in the therapeutic relationship and both play a pivotal role in the therapeutic process. Empathy is an important aspect of the relationship and involves an understanding of the thoughts and feelings of the client. Unconditional positive regard is important to the therapeutic relationship because it involves accepting the client in a non-judgmental way. Clients often enter the therapeutic space with some heavy thoughts and feelings, and it is important to approach the session with warmth and unconditional positive regard to create a therapeutic alliance that is accepting and conducive to open and honest conversation. Genuineness involves communicating in a natural and sincere way. CBT therapists should appropriately balance being hopeful and optimistic with being realistic and grounded while supporting clients. Both verbal and nonverbal expression should aim to match how the client feels and the clinician should avoid making assumptions. Rather the therapist should provide space and the freedom for the client to share how they are feeling themselves without making assumptions. We as clinicians need to be aware of our natural responses and reactions to what the client might say so that we uphold an unconditional positive regard and refrain from making the client feel judged. Interpersonal skills like expertness, trustworthiness and attractiveness are all essential aspects of therapeutic relationship in CBT and these components are important to be mindful of when practicing CBT. It is important in the context of CBT to not only provide homework assignments to clients but also ensure that we follow up on the homework assignment consistently.

    Collaborative empiricism is considered the key therapeutic alliance factor that fosters the empirical effectiveness of CBT. Identifying maladaptive cognitions and behaviors and then test for their validity and clinical utility is the main focus of collaborative empiricism. Therapist-client activity level, client-specific factors, and conceptualization and treatment are the key factors to collaborative empiricism. Clients are not passive recipients of the knowledge provided by the therapist but are actively involved in the treatment process. The therapist-client activity level will fluctuate throughout the various stages of therapy and expectations need to be set early in therapy to establish the collaborative effort to progress in sessions. In the early phase of therapy, therapist activity is high and client activity is typically low and more psychoeducation takes place in this stage. Moving toward the middle phase of therapy, the client and therapist activity level becomes more equal and reciprocal collaboration takes place. In the late phase of therapy, the client activity increases while the therapist activity decreases. This progression allows the client to become autonomous and independent and ready for discharge of services. Client-specific factors include presenting symptoms, environmental stressors and sociocultural factors which are important to consider as the therapeutic relationship evolves over time.

    CBT session structure is important to the therapeutic process and should incorporate directionality and focus so that treatment is provided intentionally. Structure is needed to carry out the effective interventions of CBT treatment. Clients often benefit from structure, and this can support the interpersonal skills needed of the therapist providing treatment. Session structure enhances therapeutic efficiency and ensures that session content remains focused on the presenting problems and toward treatment goals. I think it is so easy for the conversation to shift to topics or areas that do not relate to the treatment objectives, and it may be difficult to navigate bringing the focus back to what is clinically relevant to treatment. As the therapist, providing structure can ensure that sessions are being conducted methodologically and that clients are getting the most effective care throughout all phases of treatment. Without structure, the client would not be able to benefit as fully from the CBT interventions being introduced and it would be harder to track and gauge progress.

    Reply

    • Tayler Shea
      Sep 23, 2022 @ 19:57:52

      Hi Tom,

      I enjoyed reading your post! It was very well written. I liked how you mentioned that therapists must be careful when being hopeful/optimistic and to be sure that they are balancing reality. I also like how you described collaborative empiricism and when the client vs the therapist has more responsibility. I agree with you that session structure is very important! I thought it was interesting how much of an impact having structured sessions can make on the therapeutic relationship and how much clients trust us. You did a great job identifying the key aspect of the therapeutic relationship and session structure!

      Reply

    • Kat Gatto
      Sep 24, 2022 @ 18:56:37

      Hello, Tom, great post!

      I especially like when you mentioned how CBT therapists can best support clients by being hopeful, optimistic, realistic, and grounded at the same time. These are all extremely important characteristics that go hand in hand with collaborative empiricism! A clinician should always logically consider what the evidence may suggest would be the most helpful for a specific client. When studies show empirical support for a certain intervention then it can be easier to instill hope. Specifically, it might be comforting for a client to know that studies have shown that the approach in question has benefitted individuals with the same diagnosis. At the same time, it’s always important to readjust and recognize that the client is an individual and may need to tweak interventions in a way that best contributes to their positive therapeutic outcome.

      Reply

  10. Rachel Marsh
    Sep 22, 2022 @ 11:28:20

    Question 1
    From my understanding, collaborative empiricism refers to a therapeutic alliance that involves a team-based approach to assessing and adapting the client’s cognitions and behaviors (Volungis, 2018). In CBT, the therapeutic relationship is characterized by nonspecific factors and specific factors. Nonspecific factors refer to characteristics common with other theoretical orientations and foundational regardless of the therapeutic approach (Volungis, 2018). For example, Rogerian concepts such as empathy, unconditional positive regard, and genuineness are integral to establishing trust, cultivating an accepting environment for the client, and demonstrating commitment to the client (Beck, 2021; Volungis, 2018). Empathy refers to understanding the client’s thoughts, emotions, and experiences from their frame of reference. This means putting oneself in the client’s shoes, ensuring that verbal and nonverbal behavior is appropriate to the situation, and matching the client’s reactions. Unconditional positive regard refers to accepting the client as they are and refraining from making judgments. For example, if a counselor reacts to a client’s behavior in a non-accepting way, they are less likely to open up and disclose information to the counselor. Finally, genuineness refers to communicating naturally, honestly, and sincerely. For example, one area that is challenging to exhibit genuineness is when clients share something that elicits a strong response. In these cases, it is imperative to be self-aware of such responses.
    CBT-specific factors refer to characteristics that are more specific to CBT. The CBT therapeutic alliance is distinct from other therapeutic approaches in that it recognizes the client as an expert in their own thoughts and emotions. In the therapeutic relationship, the role of the therapist is to facilitate exploration and problem-solving rather than telling the client what they should do. The therapist offers support and direction but eventually encourages the client to become more independent in assessing and addressing their thoughts, emotions, and behaviors. Over the course of therapy, the client takes a more active role and takes charge as the sessions progress. For example, both Volungis (2019) and Beck (2021) highlight the benefits of allowing clients to set the agenda for the session and summarize the session as they have become accustomed to the CBT process.
    Question 2
    Having structure in CBT increases the effectiveness of therapy in several ways. Firstly, the aspect of structure in CBT distinguishes it from other approaches. Other approaches involve talking about stress or whatever comes to mind. CBT is more specific and aims to target the actual processes that maladaptive thoughts and behaviors stem from. For example, when thinking of psychoanalytic therapy, many individuals may think of the stereotypical client sitting on the couch discussing their problems with the therapist. This may be beneficial in part, but it lacks challenging the clients’ thoughts and behaviors. The aspect of structure gives a specific area of the client’s life to target. Subsequently, they can generalize the skills they learn to other areas of their life.
    Structure is also beneficial, especially when outlined with the client in early sessions. Many clients are hesitant to attend therapy because they are unsure of if it is beneficial, what will it entail, and how it will help. When collaborating with the client, the structure gives clients a clear idea of how each session will go and provides more insight into the specific mechanisms that will minimize their distress.
    Finally, structure in CBT is beneficial because it ensures that therapy remains focused and relevant. This is beneficial in cases where clients do not know what they would like to discuss or have too many topics to cover in one session. For clients who are unsure of what they would like to discuss, having a pre-determined structure is beneficial because it can help the therapist guide the client into what they would like to discuss.
    References
    Beck, J. S. (2021). Cognitive therapy: Basics and beyond (3rd ed.). Guilford.
    Volungis, A. M. (2018). Cognitive-behavioral therapy: Theory into practice. Rowman &
    Littlefield.

    Reply

    • Tuyen Phung
      Sep 23, 2022 @ 22:10:29

      Hi Rachel,
      I really like the way you emphasize the session structure can bring effective therapy. Specifically, it is interesting that you distinguish CBT from other approaches by session structure. I have not had a deep knowledge of other approaches. However, I also think that having a session structure is a typical therapeutic use in CBT and, as you said, it helps to deal with the root of the problem. I think that session structure helps both clients and therapists focus on the present moment rather than the past in dealing with clients’ issues. I also agree that session structure helps clients understand more about CBT and how it works for them. Clients know what they can be helped with for the day and there is a connection between the current and previous sessions in the process of treatment.

      Reply

  11. Tayler Shea
    Sep 22, 2022 @ 14:55:56

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

    The therapeutic relationship is a crucial component of CBT. In my opinion, the therapeutic relationship is comprised of qualities that help your client trust you. The therapeutic relationship is not the mechanism of change, but it is a key component in the process. The client and therapist agree to work together towards a goal (change). The client must feel comfortable with their therapist to be truthful with their therapist. Carl Rogers’s humanistic approach began the discussion of the therapeutic alliance. Rogers’s theory focused on empathy, unconditional regard, and being genuine. These three core elements of the therapeutic alliance are developed over time, and they are essential.

    Empathy consists of understanding where your client is coming from in each situation. Unconditional positive regard is approaching your client in a non-judgmental way. Genuineness is showing your client that you are invested and interested in them. These three therapeutic skills must be expressed both verbally and non-verbally. These skills will help your client feel comfortable being honest with you in session. This is important because therapy will not be effective if your client is not honest with their therapist.

    Interpersonal skills also play a role in the therapeutic relationship. These skills are expertness (client trusting you are an expert), trustworthiness, and attractiveness (likeability).

    Collaborative empiricism highlights the importance of the shared client and the therapist’s responsibility for change. Together, the client and therapist work to set goals for change and they work together on interventions to change behavior. The focus of collaborative empiricism is to identify maladaptive thoughts and behaviors and then investigate if those maladaptive thoughts and behaviors are valid or not to result in a decrease of maladaptive thoughts and behaviors.

    There are three key components of collaborative empiricism. The first component is the therapist-client activity level. This is the idea that clients and therapists must both be active in the treatment process. It is the therapist’s responsibility to inform the client that the treatment will be a team process and that there are expectations that they will work towards their change. The client and therapist must collaborate together. There will be times during therapy when the client has more or less responsibility during sessions. In the early stage, the therapist will have a high amount of activity and the client will be low (more education). In the middle phase, the therapist and client have about equal levels of activity (focus on implementing treatment goals. In the final stage of therapy, the client has more activity than the therapist and is preparing for graduation.

    The second key component is Client-specific factors refer to being sensitive to the needs of each client and understanding that each client comes from a different background. The three main client-specific factors are: presenting symptoms, environmental stressors, and sociocultural factors. The third key component of collaborative empiricism is conceptualization and treatment. This means that the therapist must gather information from the client and work collaboratively with the client to conceptualize their case and treatment plan. When the client agrees with their case conceptualization, they are more likely to succeed.

    Overall, the therapeutic relationship is crucial in making the client feel comfortable with you so that they can be honest and feel like they trust you. Collaborative empiricism is built upon the therapeutic relationship. Once the client is comfortable with their therapist, the therapist can begin explaining the collaboration that must occur for successful treatment. The strong standing therapeutic relationship will help the client and therapist work through uncomfortable elements of the collaboration and the therapeutic process.

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

    Having structure during CBT sessions is very important to effective CBT. Most clients who are seeking therapy are in need of structure and they value someone who can help them feel structed. The structure will also help build the therapeutic relationship and interpersonal skills, as the client may trust your expertise more the more structured your sessions are. Having an effective session structure will also help your client feel better quicker. This is important when working with clients who are only able to receive therapeutic services for a certain amount of time.

    Each session should be broken up into four sections: Pre-Session Stage, Early Session Stage, Middle Session Stage, and Late Session Stage. The pre-Session Stage comprises reviewing client information and any assessments before meeting with the client. This ensures that you are familiar with your client and that they feel important to you, as you can recall the last session. The Early Session Stage includes a personalized check-in, mood, and symptom check in’s which shows your client that you care about them. This also can be relevant when creating an agenda, and review of homework which allows for assessment of new skills and an opportunity for feedback regarding those skills. Setting an agenda is important during therapy so that both you and your client know where the conversation is going, and you are staying on track.

    During the middle stage of therapy, you are reviewing problems, problem-solving, and summarize the session. When reviewing the problem, it is best to notice how the problem ties into the client’s overall discomfort. It is important to ask the clients questions such as what is maintaining the problem and what the client has already tried to solve the problem. Once you have covered the problem, the therapist and the client will begin to problem solve. This requires the therapist to share different CBT skills (psychoeducation, problem-solving, behavioral activation, emotion and thought identification, modification of thoughts, relaxation, or exposure) that may provide relief to the client. Finally, during the middle stage, you will summarize with the client. You may go over what is working for them versus what is not working, how the client is feeling, ask the client for feedback, and review what was helpful versus what was not helpful. During the late stage of therapy, we are summarizing the session and its overall theme. The CBT model is integrated, and the therapist is ensuring the client understands how purposeful the session was. This is when we assign homework. It is crucial that the client understands the homework and how it was relevant to the session. Finally, ask the client how they felt during the session and how effective they feel it was. This is when you could consider changes to the therapeutic structure also.

    Overall, the structure is important in helping the client successfully change behaviors and thoughts. It helps the client trust you, and it builds upon the therapeutic relationship.

    Reply

    • Rachel Marsh
      Sep 25, 2022 @ 14:47:15

      Hello Tayler,

      I loved reading your post. I especially like the points you made regarding session structure in CBT. You make a great point when you mention that structure can aid in establishing a strong therapeutic alliance and may be more likely to perceive the counselor as having expertise. The aspect of structure shows that the counselor put thought and organization into their sessions.
      Additionally, I appreciate how you mentioned the importance of structure because of the short time we are often permitted with clients. Having structure promotes efficiency and minimizes distractions and irrelevant topics brought up in therapy. This way, we can more effectively help clients attain their goals. Overall, great post!

      Reply

  12. Kat Gatto
    Sep 22, 2022 @ 14:57:07

    (1) The therapeutic relationship between clinician and client is meant to be a collaborative alliance in CBT. I found it interesting how the term “alliance” is defined as a relationship where two people work together to accomplish a set goal (Volungis, 2019). It makes sense that clients come to a CBT session overwhelmed by one task or another. Likewise, clients’ respective diagnoses could either be exacerbating, or acting as a direct cause of, the issue. These individuals may not know where, or how, to start. A clinician who works with such individuals to pinpoint together what task(s) to prioritize, and how to address them, is of the utmost importance. This is especially crucial when considering the premise of CBT, which is that behavioral activation could potentially alter an individual’s thoughts and emotions in an adaptive way. In addition, and importantly, CBT is empirically supported. To elaborate, CBT clinicians use interventions and assessments that have been supported by peer-reviewed studies. Thus, a level of psychoeducation is likely required in order to ensure that the client understands both the process and how/why it has worked for others. This relationship, otherwise known as collaborative empiricism, is one where a clinician educates a client, and utilizes empirically supportive techniques, with the intention of addressing some previously and mutually set goal. Expertness may come into play when educating a client about certain techniques, it is important that the clinician is competently relaying any information in a way that the client understands and is not intimidated by. This action-oriented approach has the power to unleash, either directly through cognitive-modification techniques or indirectly through behavioral activation, a cognitive and emotional change within the client.

    There are many important considerations when it comes to a strong clinician-client relationship. For example, it is crucial that a client believes their clinician is an empathetic and sincere ally. However, how a clinician portrays such a characteristic is of the upmost importance. For example, I found it interesting how a validating head nod from a clinician could be misconstrued as that clinician believing the maladaptive thoughts a client is voicing. In such scenarios, it would be best to validate in a more verbal manner. Instead of nodding, a clinician could validate verbally the client’s emotions while asking whether the client wishes to reassess their maladaptive thoughts with the clinician’s help. Unconditional positive regard and genuineness go hand in hand, as a client should always feel like their clinician is accepting and sincere. Without empathy, unconditional positive regard, and genuineness a client may feel the need to hide information from their clinician or cease sessions altogether; in either case, the repercussions are detrimental to the client’s therapeutic outcome.

    (2) There are numerous reasons why session structure is crucial for a client’s therapeutic outcome in CBT. First, it is important to check in on the client’s mood so that a clinician understands how the client is feeling about their treatment thus far. Then, setting an agenda in a way that the client feels collaborated with, and aware of, how the session will go. Third, CBT involves homework assignments for good reason. If the premise of CBT is that behavior change can cause cognitive adaptations, then behavioral activation goals are meant to happen in between sessions. Therefore, it is important that a clinician asks how their homework has gone and for other positive or negative updates. If the relationship is as collaborative and understanding as it should be, then the client would feel free to share any obstacles they encountered trying to accomplish their goals. This is a wonderful opportunity for a clinician to collaborate with their client on how to make the goals more achievable for the upcoming week. After prioritizing the agenda, a clinician may alter previously used techniques, with the client’s approval, so that it best suits the goal at hand. An action plan can be broken down into three parts, while prioritizing part one and reaching parts two and three if there is enough time left in the session. This would flow naturally with any feedback where a client could not fully accomplish the past week’s homework. Specifically, a clinician can make altering that unachieved goal, with the client, part one of the agenda. Then, a clinician should summarize what they have gone over so that the client is reminded, and feels further validated by, the clinician. They will go over the upcoming week’s action plan, and the clinician should request any feedback from their client. Feedback is crucial and works to strengthen the therapeutic alliance. When a client is working towards positive change, it can be extremely validating for them to feel like their clinician is not above changing their approach with the client when needed and applicable. In conclusion, the premise of the therapeutic alliance, and the therapeutic outcomes of the client, are maintained by such a fixed and collaborative session structure.

    Reply

    • Rachel Marsh
      Sep 25, 2022 @ 14:58:10

      Hello Kat,

      I loved reading your post! I especially enjoyed your insights on the therapeutic alliance. Specifically, I like how you discussed expertise and psychoeducation in collaborative empiricism. It takes a certain level of knowledge to know how to accurately communicate the therapy process to the client’s level of understanding. If the client feels that the process is either too simple or too complex, this may discourage them from going further with therapy.
      Moreover, you bring up a great point when you mention the integration of psychoeducation in this process. Knowing how the process has worked for other clients is also beneficial because it can provide the client with an understanding of how the process might be able to help them as well. Overall, great post!

      Reply

  13. Kristin Blair
    Sep 22, 2022 @ 15:22:30

    My understanding of the therapeutic relationship in CBT is that it is most productive and valuable in a collaborative way. In other words, the therapist makes the client an extremely active participant throughout their personal therapeutic process. You could even go as far as to call it an “alliance” more so than a relationship, due to the fact that both people are working together towards the same goal! Additionally, the assessments and intervention techniques that are used in sessions to achieve the client’s goals are based on empirically backed research and scientifically supported data, while also utilizing the information that is received from the client. The term collaborative empiricism is a true foundational term in CBT and is quite critical to ensure that the therapist is offering the best quality of care possible. Collaborative empiricism is essentially a strong therapeutic bond that is rooted in action and facilitated by proven research that accommodates, investigates, and reshapes a client’s thoughts and behaviors.

    Session structure is essential in CBT because, well, for starters, most clients want and need structure. Those who seek out therapy are typically in a vulnerable state, and having a structure from the very beginning, helps to impart a sense of contentment and the prospect that treatment might be able to help them with the current stressors. Furthermore, it helps establish the clinician as trustworthy, intelligent, and “attractive.” These factors will only help strengthen and develop a therapeutic alliance.

    Reply

  14. Teresia Maina
    Sep 22, 2022 @ 16:05:43

    Having a good therapeutic relationship is essential in CBT. It’s a collaborative relationship in which the client and therapist are active participants working towards a specific goal. Having a positive relationship helps clients feel respected, cared for, and comfortable exploring their past trauma. In the early phase of therapy, the relationship is more teacher-student but session continues it becomes more of a mentor-protege relationship. Collaborative empiricism is key in the therapeutic alliance. The focus is to identify maladaptive behavior and thought and test how valid they are.

    The session structure is essential because it helps maximize efficient use of time during sessions, but also makes the process clearer for clients. Most of our clients need or want some type of structure. It gives them hope and puts them at ease that therapy might work. It also helps to demonstrate that the therapist is an expert and trustworthy. Depending on what phase of therapy you are in it will tell you how much structure is needed in the session. During the early phase, you will require more guidance and structure although as sessions progress you might not need as much structure.

    Reply

    • Amanda Bara
      Sep 22, 2022 @ 21:49:49

      Teresia,
      Your discussion post was informative and thoughtful. I like how you pointed out that having a good therapeutic relationship makes the client feel respected. I feel like this was a term that we have not really touched upon in regards to the therapeutic relationship but it is so important. Making the client feel respected also helps to build that sense of trust and expertness that have been previously discussed. You did a great job at identifying the important aspects of session structure. I also think its important to focus on each client as an individual and how they may respond to a very structural approach to therapy. Very insightful!

      Reply

  15. Sam Keller
    Sep 22, 2022 @ 19:42:14

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

    The therapeutic relationship is an alliance between the therapist and the client. The therapist should have a good working relationship with the client, one where the client feels open to talking about sensitive issues and feels like the therapist isn’t working against them. The client and the therapist should be collaboratively working towards client goals. Three of the main traits from the therapist that lead to a successful therapeutic relationship are trustworthiness, attractiveness, and expertness. Trustworthiness is a respect for client’s boundaries, being reliable in session, and keeping confidentiality. Attractiveness is being likable, compatible with the client’s personality, and being malleable in your approaches to treatment. Expertness is presenting information to the client in a confident way and being able to explain treatment methods in a way they understand. Collaborative empiricism is an alliance between the client and therapist where they are able to use data based interventions to take an objective look at thoughts and behaviors. We want to approach modifying thoughts and feelings in a data-driven systematic way.

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

    It is important to have a plan and structure for sessions in therapy. Most clients want a sense of organization and expectation in therapy. There is a sense of security in having a known pattern of expectations in therapy and it also helps convince beginning clients that they will see results. It also allows you to better keep track of progress because you know a certain subset of the information you will be getting in session. Having a plan beforehand allows both the therapist and the client to be more goal-oriented in session. It can also allow you to be more efficient with your time (the saying ‘time is money’ comes to mind). Structuring sessions in a certain way works best when the client is introduced to and habituated to this in the beginning of therapy.

    Reply

    • Amanda Bara
      Sep 22, 2022 @ 21:46:24

      Hi Sam!
      I think you did a great job at highlighting the three main traits that a therapist must lead with in order to establish a strong foundation with a client. Being trustworthy is so important for clients to open up about their struggles and dive deep into what has made them the person they are. I think you did an awesome job at defining collaborative empiricism and focusing on the data driven background of cognitive behavioral therapy. One important feature of session structure that you noted was that most clients want to have some sort of expectation when going into therapy. I think this goes a long with the therapist and treatment goals as there needs to be some sort of end goal or bigger picture for both the client and therapist. Nice job!

      Reply

    • Kat Gatto
      Sep 24, 2022 @ 19:01:48

      Hello, Sam, awesome post!

      I especially enjoyed when you said that clients can be comforted by a level of expectation, regarding what the session will entail, coming into therapy. I can see this being true for many individuals who have anxiety or feel like their lives are chaotic in one way or another. For these individuals, it may be extremely beneficial for them to feel like an hour or so is devoted to trying to improve their livelihood in a somewhat predictable way.

      Reply

  16. Vanessa U
    Sep 24, 2022 @ 03:15:35

    The development of a therapeutic that is bonded
    The therapeutic alliance is arguably the most important factor in both, establishing & developing a foundation for success. It is a unique bond between therapist and client that is crucial to reaching the most optimal level of therapeutic benefit.
    Several years ago, I had the advantage of entering the field of juvenile probation with a clinical background. Over the course of the last decade, I have observed the court system struggle to implement the most basic elements of CBT. When I left the court in 2020, the focus had still yet to deter from the false illusion of power and control.
    While the rewards in that profession are few and far between, I felt the most element of success in developing a rapport with some incredibly resilient and challenging humans. Whenever possible, I consistently adopted aspects of the Therapeutic Alliance into my work with a diverse cross section of the public. I found it highly effective in building a similar bond of trust and consistency with families I was hired to serve. More often than not, it leads to a mutual respect that allows you to work in collaboration with parents and their children. While not often, there were still a few officers that stuck to a far more directive / adversarial approach. Not shockingly, it rarely worked. And in some cases, it became a vehicle of contention that could easily result in unnecessary, extended court involvement. In most circumstances, to veer from all forms of collaborative empiricism does a real disservice.

    Reply

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Adam M. Volungis, PhD, LMHC

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