Topic 3: Therapeutic Relationship & Session Structure {by 9/23}

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 9/23.  Have your two replies posted no later than 9/25.  *Please remember to click the “reply” button when posting a reply.  This makes it easier for the reader to follow the blog postings.

33 Comments (+add yours?)

  1. Frayah Wilkey
    Sep 20, 2021 @ 18:58:53

    1. Based on the assigned readings, it is clear that the therapeutic relationship is an essential aspect of effective CBT. While it is not the primary mediator of change, it plays a vital role in the client’s success and outcomes, as well as overall satisfaction with the process. Research suggests that a high quality therapist–client relationship is positively related to good treatment outcomes. Alternatively, a negative relationship between the two parties can contribute to negative outcomes. This suggests that the therapeutic relationship is an important facet of CBT, one that therapists should take time to educate themselves on so that they can be more effective during sessions. Clinicians can do this by actively participating in sessions and encouraging clients to do the same, while continually checking in throughout the progression of sessions. Clinicians should also take care in ensuring that they are meeting some basic standards, such as being trustworthy and attractive.

    There are different ways to establish the therapeutic alliance. There are factors specific to CBT which contribute to the alliance. These factors are necessary for collaborative empiricism, which is action-oriented and supported by research. It aims to integrate, test, and modify the client’s thoughts and behaviors through CBT sessions. The clinician will begin by identifying maladaptive thoughts and behaviors. They will then test them for their empirical validity utility, therefore increasing their adaptive functioning. The three key components of collaborative empiricism are therapist–client activity level, client-specific factors, and conceptualization and treatment. All components should be considered by the therapist during both initial and subsequent sessions to ensure that collaborative empiricism is being supported.

    2. The clinician should take care in establishing session structure early on. Oftentimes, clients feel vulnerable and distressed when beginning therapy. Established structure in the very first session can reduce their negative feelings and allows them to feel more confident in their decision to enter therapy with a seemingly effective therapist. It also allows the clinician and client to set up a general timeline and direction which will foster efficacy throughout the treatment. Sessions will run more smoothly when there is a pre-determined structure that is consistently followed. The structure may slightly change depending on the session number or based on client characteristics, but overall, it is an essential component of effective CBT.

    Reply

    • Jennifer Vear
      Sep 21, 2021 @ 12:37:53

      Hi Frayah,

      You did a great job describing how important it is to have a great therapeutic alliance for the therapy session to be truly effective.
      When I was younger, I did not have a great experience with my first therapist. She sat slumped in her chair the entire time, looked at the clock frequently, never said a single word, and then, worst of all, took a phone call during one of our sessions. It was so bad, I only lasted a few sessions and then never went back. Luckily, years later, I decided to go back and found a really great therapist. However, there are people out there that would never go back after just one terrible interaction. If the therapeutic alliance is bad, it will not just damage the client’s sessions, but could also decrease the likelihood of that person seeking out a better therapist. It could turn them away from therapy completely, which is very unfortunate.
      I have definitely learned a lot from that first therapist, which was how to NOT act.

      Overall, great job!

      – Jenn

      Reply

      • Morgan Rafferty
        Sep 22, 2021 @ 12:20:21

        Thank goodness you didn’t give up after that negative original experience with therapy Jen. That is unfortunate and it sounds like she was lazy. I wonder what her intent was? I would find that to be intimidating especially at a young age. It could almost feel like punishment. It makes me wonder and worry if there are therapists out there who get lazy especially when working with kids because kids don’t have the ability to hold a therapist to a certain standard.
        I like your attitude of taking away from it how not to be as a therapist.

        Reply

    • Giana Faia
      Sep 22, 2021 @ 20:44:51

      Hi Frayah,

      I like how you pointed out that the therapeutic relationship is not the mediator of change but does play a key role in the outcome of therapy. By establishing a therapeutic relationship early on, it can increase the likelihood of positive outcomes. Demonstrating trustworthiness, expertness, and attractiveness helps build the relationship and allows for the client to feel comfortable and safe during therapy. With the client feeling comfortable and safe, it can allow for them to open up more which intern allows us to help. Thanks for sharing.

      Giana

      Reply

    • Lisa Andrianopuolos
      Sep 22, 2021 @ 21:57:00

      Frayah,
      Great point that establishing a structure and using it consistently, will help the session run more smoothly! It takes the guesswork out of it. Everyone knows what to expect and no one is floundering wondering where to go next or what the purpose is. This is what makes CBT so attractive as a therapy. It all makes sense to both the client and the therapist.

      Reply

  2. Jennifer Vear
    Sep 21, 2021 @ 12:28:51

    1. For a therapy session to be truly effective for both the therapist and the client, there needs to be a strong therapeutic alliance. This relationship will have a stronger impact on the client’s development throughout the treatment process. By establishing a strong and positive foundation, the sessions will be conducted through collaborative empiricism. According to the text by Dr. Volungis, collaborative empiricism includes a strong and positive therapeutic alliance that is action-oriented in modifying a client’s thoughts and behaviors. This collaborative empiricism can be achieved through nonspecific factors and/or CBT-specific factors. Through nonspecific factors, a therapist can use basic skills of empathy, unconditional positive regard, and genuineness to gain the trust and acceptance of the client. Furthermore, interpersonal skills of expertness, trustworthiness, and attractiveness are also nonspecific factors that can help to improve this collaborative relationship alliance. Then lastly, CBT-specific factors include working with the client through a therapist-client activity level through the different phases of therapy and also taking into account a client’s presenting symptoms, environmental factors, and sociocultural factors. Without awareness of these various factors, the client might not feel completely understood, listened to, or trusting of the therapist’s abilities to help them. Overall, each of these examples of nonspecific and CBT-specific factors will increase the likelihood of a therapeutic treatment benefiting through a collaborative experience.

    2. Having a session structure in CBT practices allows for the client to feel more at ease in sessions, helps to develop a more positive therapeutic relationship, and helps to introduce the client to the CBT process. Session structure also gives the client and the therapist a sense of direction that is geared around CBT and the client’s goals for treatment. Without structure, the client could become confused about how many sessions they are going to be involved in, they might not feel as if they have any sense of direction that will lead to them getting better, and it could detriment the therapeutic alliance if the client believes that the therapist looks unorganized and inexperienced. In the early session, it is important to always check up on how the client is feeling, set the agenda so both parties know what the focus is for that session, and also to review any homework that was assigned in the last session. This session structure also shows the therapist what is working for treatment and what might not be working. If the client is not getting better, the structure will show the therapist where they might need to modify their approach and allows the client to be aware that the therapist is working towards the client’s goals. This can be shown through how the client did in their last homework assignment. The therapist can then either continue with their treatment or modify their treatment in the next homework assignment. In the middle session stage, the therapist can review any problems, work on problem-solving strategies, and then give/receive feedback to make sure everything is working and summarize the main points from the session. Then finally, homework is assigned at the end of the session to allow the client to continue their progress from home. With this constituent session structure, the client is always aware of what will be going on, and is beneficial for both the client and the therapist to assure that they are in the right direction for the client’s treatment process.

    Reply

  3. Kaitlyn Tonkin
    Sep 21, 2021 @ 16:11:14

    1. A therapeutic relationship in CBT is one of the fundamental components of therapy and is a major factor in how therapy progresses for the client. The quality of the therapeutic relationship is incredibly important because it can greatly influence the well-being of a client. This is true for poor therapeutic relationships as well; the poor quality can sometimes make the client worse. Forming a strong therapeutic relationship is imperative for a client to make progress in therapy. A client will not feel like they can share personal things about themselves if they do not trust the therapist they are working with. So, having this strong relationship is necessary for the client to make progress. Furthermore, having a strong relationship has been shown to enhance therapy outcomes, again showing how important this relationship between the client and therapist truly is. It is important to note, though, that the therapist and the client are active participants throughout the therapeutic process. In this relationship, the client and therapist work together to define problems and learn and develop skills to modify thoughts and behaviors. This is a process called collaborative empiricism. As explained by Volungis (2019), collaborative empiricism is “an action-oriented therapeutic alliance driven by research that integrates, tests, and modifies clients’ thoughts and behaviors” (p. 11). The primary focus of collaborative empiricism is to identify maladaptive cognitions and behaviors and then test for the validity or utility. Collaborative empiricism is also helpful because it tends to result in more adaptive cognitions and behaviors, a reduction in the frequency and severity of symptoms, and an improvement in overall quality of life. There are three key specific factors of collaborative empiricism that are important to note which are therapist-client activity level, client-specific factors, and conceptualization and treatment.

    2. Session structure is important in CBT because many clients want and need structure. Since clients are distressed and suffering in some kind of way, structure is important in therapy because it instills hope and comfort that their symptoms can be managed and relief is possible. Additionally, session structure gets the client socialized with CBT and allows the therapist to model the collaborative nature that is CBT. Session structure is important for effective therapy because it provides both the client and the therapist with direction in therapy and shows how therapy can progress. Session structure also enhances therapeutic efficacy by creating organized therapy. Sessions should be broken down into four phases (pre-session, early session, middle session, and late session) to allow for easy flow and organization of the session. I think this is also important because each session is only 50 minutes long, so it is important that the necessary things are covered, but that the therapist or client does not spend too much time on any one subject. Having structure that has already been outlined or discussed is helpful for moving along if the client or therapist gets stuck on a certain topic.

    Reply

    • Jennifer Vear
      Sep 22, 2021 @ 10:43:02

      Hi Kaitlyn,

      You did a really great job describing both the importance of session structure and collaborative empiricism. The session structure is especially important because, without it, the therapist could have a whole session go by without performing any true CBT skills or having any true direction. This can also make it hard to track the client’s progress as you said. I am excited to learn more about the session structure and how to keep clients on track, especially if they are all over the place!
      Overall, great job!

      – Jenn

      Reply

    • Morgan Rafferty
      Sep 22, 2021 @ 12:15:16

      Great post Kaitlyn. You were thorough and clear in your description of the importance of the therapeutic relationship in CBT.
      I agree with you that one really important need for session structure is the time limit of each session. I have been amazed by how quickly a session with my therapist flies by! As a client, I needed to go through a learning curve on my end in terms of realizing that I did not want to waste time; every minute counts! And costs me money as well! My therapist is not terribly structured unless I give her room to take the reigns. It’s a interesting back and forth dance for us.

      Reply

    • Lisa Andrianopoulos
      Sep 22, 2021 @ 22:02:48

      Kaitlin,

      I like your point about the length of the session. It is only 50 minutes and the structure really does maximize the use of your time. With structure, the client and therapist lead the session feeling like maybe they’ve accomplished something. As the readings indicate, providing structure keeps the sessions goal oriented. As you proceed through the agenda (with room for flexibility of course), small goals are accomplished along the way, which instills hope that larger goals can also eventually be met.

      Lisa

      Reply

    • Valerie Graveline
      Sep 22, 2021 @ 22:24:35

      Hi Kaitlyn,

      I really enjoyed your explanation about the importance of the therapeutic relationship, I thought you articulated it very well. It’s crucial for the client to feel that the clinician truly cares about them, in order for the client to open up and trust them with things they may not have told anyone else. I think a lot of times people who have not been to therapy overlook how hard it can be to open up to a stranger in this way. I also think that’s why it’s super valuable for all of us in this program to have experience as a client in therapy so that we can truly understand how that feels. I definitely agree with you that a strong therapeutic relationship is completely necessary for a client to make progress and to ultimately terminate with long-term, positive therapeutic outcomes.

      Valerie

      Reply

    • Katie O'Brien
      Sep 23, 2021 @ 10:50:00

      Hi Kaitlyn,

      I liked how you made note of the pre-session, early session, mid session and late session stages, and how important they are given the timeframe therapists have to work with their clients. With such little time, it is really important to maximize every minute with a client. One of the things that stuck out most to me was simply taking a few minutes to prepare before even being in the room with the client. It seems almost like common sense, but is likely a step that is skipped, due to being short on time or perhaps laziness on the therapists end. It seems if we’re giving clients homework, we should do the same as well and be as prepared as possible going into a session. Not only will it help us to seem like we know what we’re doing to the client, but it’ll also help to show them we do care about what they’re going through. Good point!

      Thanks,
      Katie

      Reply

  4. Morgan Rafferty
    Sep 22, 2021 @ 12:04:09

    1.) The therapeutic relationship in CBT is more than a relationship. It is an alliance. It involves a collaborative process. In order for effective outcomes to result, the therapist and the client must both be active participants and work together toward mutual goals. This alliance aligns with collaborative empiricism meaning it is action-oriented and driven by research that integrates, tests, and modifies clients’ thoughts and behaviors.
    Although the therapeutic alliance is not the primary process for change in CBT, it is essential for obtaining desired treatment outcomes. The quality of that alliance can result in either a negative or positive impact on the client. Factors important for a therapist to possess and demonstrate in establishing a positive therapeutic alliance are: empathy, unconditional positve regard, genuineness, interpersonal skills, expertness, trustworthiness, and attractiveness.
    Collaborative empiricism is the key therapeutic alliance factor that fosters the overall empirical effectiveness of CBT. The primary focus is to identify maladaptive cognitions and behaviors and then “test” for their empirical validity and/or utility. The result is often more adaptive cognitiions and behaviors, a reduction in the frequency and severity of symptoms, and an improvement in overall quality of life.

    2.) Most clients want and need session structure. It is important to create it from the first session through the last. It instills comfort and hope within clients. Session structure also demonstrates that you as a therapist are an expert, are trustworthy, and attractive. Session structure provides direction for both you and your client. It also allows for modelling on how to approach and solve problems related to client distress. It enhances the efficiency of CBT which is significant because the more brief a period of time a client is suffering, the better. Additionally, insurance will only allow for a set number of sessions.

    Reply

    • Frayah Wilkey
      Sep 22, 2021 @ 18:13:30

      Morgan,
      I really liked how you described the alliance between a therapist and client. It is so important for both parties to be on the same page so that sessions can run smoothly and effectively. As you mentioned, both need to be involved in the decision making throughout the process so it is important that the client is able to vocalize their needs and wants. Thank you for sharing your thoughts!

      Frayah

      Reply

    • Giana Faia
      Sep 22, 2021 @ 20:57:51

      Hi Morgan,

      I appreciate how you pointed out that clients want and need structure in sessions. In the early session, clients usually don’t know what to expect. By having structured sessions, the client can start to feel more comfortable and hopeful that they will gain relief from their distress. Structured sessions are also important for not only the client, but there realist as well. It provides direction for both which relates to therapy being a collaborative process. Thank you for sharing.

      Giana

      Reply

    • Katie O'Brien
      Sep 23, 2021 @ 11:48:09

      Hi Morgan,

      I liked the more logistical points you made about session structure. We know CBT is great because it offers more relief in a shorter timeframe, but your point avoided insurance is also really important. It stinks that care has to be in part, determined by insurance. But as you said, having structure allows us to show that the CBT skills are working, as compared to other techniques that may not have as measurable outcomes.

      Thanks for pointing that out!

      Katie

      Reply

  5. Giana Faia
    Sep 22, 2021 @ 13:54:52

    1. To me, establishing a therapeutic relationship is crucial in therapy. In order for the most positive outcomes of treatment and therapy, a strong therapeutic relationship and rapport should be established. In CBT, it is important that both the client and the therapist are both actively participating to ensure that it is a collaborative process for the best outcomes. In forming the therapeutic relationship, it is necessary to demonstrate empathy toward the client. This means to show understanding of the clients thoughts and feelings as they view them. Along with this, it is important to demonstrate expertness, trustworthiness, and attractiveness. With expertness, you want the client to see that you know what you are talking about and that you have the proper training. It is also important to provide clear roles and expectations to the client. Trustworthiness is consists of your reputation as well respecting client confidentiality, following the right policies and procedures, and showing that you are reliable. The more trust that is developed, the more the client will share, resulting in better treatment and outcomes. With attractiveness, it is about how the client perceives you. It is important to be likable and compatible with the client, and you may have to adjust to be compatible with the client. It is important to be sincere, genuine, and demonstrate unconditional positive regard to ensure that the client does not feel judged. With all of these factors, you want to make the client feel as comfortable and safe as possible as a way to increase the chance of positive outcomes.

    An action-oriented therapeutic alliance that is driven by research is collaborative empiricism which aims to integrate, test, and modify clients’ thoughts and behaviors. Collaborative empiricism consists of three key factors which are therapist-client activity level, client-specific factors, and conceptualization and treatment . Therapist-client activity level involves setting expectations early and explaining that both the therapist and the client should be active participants in therapy. Client-specific factors involves still being mindful and flexible when it comes to the clients presenting problems/ distress. Conceptualization and treatment involves understanding both the clients strengths as well as how they influence their own distress. Along with this, identifying and modifying maladaptive behaviors and thoughts is part of treatment and can be distressing, so it is important the client trusts you during this process.

    2. Having session structure is important for effective CBT for many reasons. First, it helps the client to feel comfort and hope for their therapeutic experience. Clients usually feel more comfortable when treatment is structured and has a purpose. If a client feels hopeful of getting relief from their distress during the first few sessions, it will lay the foundation for how the rest of their therapeutic experience will go. It also helps show the client your expertness, trustworthiness, and attractiveness. If you provide structure to sessions, clients will see you know what you are doing rather than it being unstructured and they don’t know where the sessions are going or what to expect. With session structure, it gives direction for both therapist and the client. Another reason session structure is important is because it facilitates organized therapy by focusing on the relevant issues as well as goals and treatment. This ultimately increases therapeutic efficiency.

    Reply

    • Frayah Wilkey
      Sep 22, 2021 @ 18:16:19

      Giana,
      I like that you brought up the importance of feeling empathy toward clients. Oftentimes, clinicians work with people who may be difficult or frustrating due to their circumstances. Clinicians must remain empathetic to them though to ensure that the therapy is effective and compassionate. It can sometimes be hard to feel empathy in all situations but it’s a necessary component to CBT. Thank you for sharing your thoughts with us!

      Frayah

      Reply

    • Kaitlyn Tonkin
      Sep 23, 2021 @ 10:54:51

      Giana,

      You make a great point that having structure in therapy sessions shows your expertness, trustworthiness, and attractiveness as a therapist. As we have learned, these are all crucial aspects of being a therapist, so it is important that clients can perceive this as well. Like you said, providing a structured therapy session allows the client to feel like you know what you’re doing and have a plan for their success, rather than not having structure and just going with whatever when the session begins. Thanks for making such a good point!

      -Kaitlyn

      Reply

  6. Lisa Andrianopoulos
    Sep 22, 2021 @ 21:52:29

    1) In CBT, the therapeutic relationship is critical. Also known as the therapeutic alliance, this relationship is important because a core component to CBT is the collaborative nature between the client and therapist. For this collaboration to be effective this relationship must be strong. Research supports that, if the relationship is positive, the therapeutic alliance has important implications for treatment outcomes and overall improved quality of life. Implicit in the relationship is what is called “collaborative empiricism.” This is a goal-oriented approach in which the client and therapist together actively work on interventions as well as test and modify client’s thoughts and behaviors. It is a shared responsibility between client and therapist with a primary focus on identifying maladaptive behaviors and cognitions and “testing” them for their validity or usefulness. For this working relationship to be most effective the client must trust the therapist and be willing to take the risks to actively participate and acknowledge maladaptive thoughts in sessions. Said another way, the client must trust you, which comes from a strong relationship, if they are going to take the leap of putting themselves at psychological risk.

    2) CBT is one of the only therapies that is highly structured. In fact, structure is a key feature of CBT. As said above, CBT is highly collaborative between the therapist and client. Structure elicits active participation from the client and lends itself to creating a collaborative atmosphere. It also keeps the session goal oriented. Agenda setting. in particular, sets the stage for the flow of the session. Also, from the first session and moving forward, structure provides purposeful directionality and focus for both the client and the therapist. Especially in the beginning, clearly defining the structure also improves the likelihood that the client will perceive you as an expert, attractive and trustworthy – factors research has shown to improve the therapeutic relationship and client engagement; thereby increasing the likelihood that the client will buy into the treatment and more specifically, try the interventions you work on in sessions in their daily lives. Clients also feel better when there is a sense of structure and purposeful treatment because it builds hope and expectation that recovery/improvement is possible

    Reply

    • Valerie Graveline
      Sep 22, 2021 @ 22:13:50

      Hi Lisa,

      I thought you made a very good point when you said that the quality of the session structure can help improve the client’s view of the clinician, portraying them as expert, attractive, and trustworthy. With this said, I feel as though most clients would prefer a session with clear structure and formulated goals, rather than a session where the pressure is seemingly on themselves to raise and address issues with the clinician out of nowhere. I also think it’s very valuable within the session structure of CBT to initially address the client’s goals of the session and/or overall treatment so that the client understands that the session will be focused and efficient, rather than randomly jumping from topic to topic without a clear purpose.

      Valerie

      Reply

  7. Valerie Graveline
    Sep 22, 2021 @ 21:58:24

    1) The therapeutic relationship in CBT is bidirectional, involving effort on both the clinician’s side and the client’s. The therapeutic relationship is often viewed as an alliance between the therapist and the client because it involves a collaborative effort in working toward treatment goals. It is the clinician’s responsibility in early sessions to create a comfortable environment for the client by establishing rapport and trust so that the client feels safe to open up to them. At the same time, to establish that it is a collaborative environment, it is important for the clinician to incorporate feedback from the client about the session and to explain the purpose of different interventions so that the client understands that they play an active role in their therapeutic treatment. In CBT, the therapeutic relationship emphasizes collaborative empiricism, which J. Beck (2o20) describes as a clinician helping their client determine the accuracy and utility of their thoughts by reviewing the evidence that may be present. Furthermore, Volungis (2018) states that the purpose of collaborative empiricism is to ultimately modify clients’ maladaptive thoughts and/or behaviors into adaptive ones following the examination of such evidence. It is crucial for the therapeutic relationship to be not only strong, but positive, considering the quality of the relationship can greatly impact the therapeutic outcomes of the client.

    2) It is important to have session structure in CBT as it enhances the efficacy of the treatment process. With session structure, it allows both the clinician and the client to feel more organized with respect to the goals of the session and/or of treatment. In CBT, session structure is typically formulated both prior to the session and within the session as the client begins to open up about their current issues. Based on the reading by J. Beck (2020), session structure is valuable because it allows the clinician to learn what issues/goals are important to cover in the session, while allowing the client to decide what they feel is most important to address during the session. Also, the way the session structure is presented to the client helps the client further understand that their therapeutic treatment involves a collaborative approach. For example, in the J. Beck (2020) reading, she initially asks her client to briefly discuss what happened throughout the week and following this, she summarizes what was stated and proceeds to address a way they can plan to move forward in the session. As she does this, she asks her client if that structure works for him as well, furthering the idea of a collaborative environment. Session structure is important for effective CBT as it provides the clinician a clear path to follow for treatment, so that the session can be as productive and valuable as possible for the client.

    Reply

    • Francesca Bellizzi
      Sep 25, 2021 @ 18:25:01

      Hi Valerie,

      Awesome post! I particularly liked the way that you integrated examples from Beck to exemplify the importance of structure during a CBT session. Very thorough and evidenced explanations for both questions… thanks for sharing!!

      All the best,

      Francesca Bellizzi

      Reply

  8. Sergio Rodriguez Pineda
    Sep 22, 2021 @ 22:20:53

    1. One of the most important elements of the CBT (if not the most) is the “Therapeutic Relationship”. Research has demonstrated that a positive therapeutic relationship is correlated with favorable treatment outcomes. Beck highlights some core components like demonstrating good counseling skills and accurate understanding, share the therapist’s conceptualization and treatment plan, collaboratively make decisions, seek feedback, vary the therapist’s style, and help patients solve their problems and alleviate their distress. There are three elements to analyze deeper. The first two are: seek for feedback and vary style, these two can be challenging because they set up the therapist in a position where he/she must ask for feedback from the patient about the session and the procedures with questions like what were your thoughts on the session? Or was there anything that bothered you, or did you think I misunderstood something? Those questions create a smooth atmosphere with the client and will shape the flexibility (vary) or opportunity to do things differently to obtain a better result. The third element to discuss is connected to the previous two and is the ability to collaborate with both patient-therapist in developing a treatment plan. This leads to explain the concept of collaborative empiricism, which involves cohesiveness between the patient and the therapist as they explore the patient’s aspects that contribute to dysfunction together through discovery and experimentation.

    2. It is important to have a session structure for effective CBT because the therapist should conduct therapy as efficiently as possible. The main reason is that when clients come to therapy most of the time they’re going through difficult situations and the therapist’s efficiency will help to relieve the patient’s suffering as quickly as possible. Following these thoughts, the structure of a session is essential because adding a standard and organization. Patients do better when they know what to expect when the patient feels part of the therapy as a team and they can understand the different stages of the therapy and their anticipated achievements and progress. However, one key aspect of the structure is flexibility. CBT considers multiple patient factors like symptoms, the strength of the therapeutic alliance, their stage of treatment, and, especially, the problems they put on the agenda to be treated. All of these elements are essential to establish and modify the therapy plan as needed.

    Reply

    • Francesca Bellizzi
      Sep 25, 2021 @ 18:20:49

      Hi Sergio,

      Great explanation of the therapeutic relationship and its importance! I really enjoyed the addition of ways to seek feedback in order to better understand how the relationship is going. I thought it was a nice way of integrating things that we have learned in other classes to further expand on its importance.

      All the best,
      Francesca

      Reply

  9. Francesca Bellizzi
    Sep 23, 2021 @ 09:15:04

    1. From my exposure to CBT through readings and class time, it is apparent that the therapeutic relationship is a fundamental aspect of the process. While the primary focus of CBT is to address maladaptive thoughts and behaviors, it is a process that incorporates working together to make appropriate and effective modifications. Here, the therapist and the client are equally active throughout the process and work together towards goals that are mutual. Research has uncovered that strong therapeutic relationships positively interact with treatment outcomes. Part of this relationship is a concept called collaborative empiricism. The primary focus of collaborative empiricism is for the therapist and client to work together in order to identify maladaptive thoughts and behaviors. Once these thoughts and behaviors have been identified, they further collaborate to challenge their validity and create a therapeutic alliance. If the relationship between the therapist and the client is not one that is strong, then it may be difficult to explore these maladaptive tendencies in full. Similarly, a client may feel as though they cannot share certain information if the relationship is not strong because there may be an aspect of trust that feels missing. Not only does this relationship need to be strong, but it also needs to be positive. According to Rogerian qualities, a therapist can create this positive relationship by expressing unconditional positive regard, genuineness, and empathy when initially interacting with the client. Overall, the therapeutic relationship is an extremely influential aspect of CBT as it creates a foundation for working collaboratively and having positive treatment outcomes.

    2. It is important to have session structure for effective CBT in a number of ways. When thinking of the client, sometimes a person may seek therapy in order to gain structure and be given direction. The structure of the session also helps the client gain comfortability with CBT as it socializes them to the process, allowing their understanding of the therapeutic process to grow. Not only is session structure useful for the client, but it also benefits the therapist by providing direction. Through utilizing the directive nature of session structure, it allows the therapist to exemplify their expertness and helps to organize information gathering. This organization may help increase a therapist’s understanding of the client’s presenting problems and create a hierarchy based on relevance and distress when attempting to address maladaptive thoughts, feelings, and behaviors. Lastly, session structure is important to have for effective CBT because it increases the efficiency of the sessions. This level of organization helps the client and therapist focus on problems that are the most relevant and keeps treatment and interventions on track by focusing on the corresponding goals. All in all, the structure is important for effective CBT sessions because it helps the client and therapist stay on track and organized, while also providing a level of comfortability that leads to the formation of a strong therapeutic relationship.

    Reply

    • Lindsay O'Meara
      Sep 25, 2021 @ 09:45:31

      Hi Francesca,

      I love that you accentuated the fact that the client and therapist work together as a team to combat the troubles that the client is facing. Comradery between client and therapist is such an important factor in CBT. I think that it is imperative that the therapist is present for the client and able to keep the client engaged and interested in collaborating with them. I’m personally someone who needs structure, so I can understand how important session structure can be to both the client and therapist. We want to make sure that we’re focusing on the big picture and helping to move the client in the direction they want to.

      Reply

  10. Katie O'Brien
    Sep 23, 2021 @ 10:42:21

    1.) While not the major change process in CBT, the therapeutic relationship between therapist and client has been shown to have a large effect on treatment outcomes. Not only does a positive relationship help produce better outcomes, but a poor relationship between therapist and client may also be damaging to a clients progress, as well. As CBT is focused on modifying maladaptive automatic thoughts and core beliefs, clients may sometimes feel ashamed or embarrassed regarding these thoughts. Because of this, it is incredibly important for a client to feel comfortable opening up to their therapist and for them to have a sense that they can trust the therapist with these negative thoughts, instead of being ashamed and not opening up. If that were the case, it would be difficult for treatment to progress, as they may not be getting at the real issues the person is experiencing. In CBT in particular, this relationship is more of an alliance, with both parties working collaboratively to make changes. Collaborative empiricism refers to the idea that this alliance, made up of therapist and client, will work together as a team, using evidence and research based practices and techniques in order to make changes in the client. While the therapist plays the role of guiding the client and providing psychoeducation about these practices, the client must also be a working member of the alliance in order to follow through and implement the changes discussed during the session. In CBT, the work does not fall only on the therapist or only on the client, rather both parties will contribute, sometimes more or less depending on the stage of treatment.

    2.) Session structure is incredibly important in CBT for a number of reasons. First, it aids the therapist in seeming professional and knowledgeable, a major component of the therapeutic relationship, but it also helps clients to feel more comfortable in the beginning of therapy. As treatment progresses, it is necessary to have structure and even agendas for each session in order for the therapist-client alliance to track a clients progress in treatment. It allows both parties to reference the work done in the previous session, as well as between sessions, and see if any changes need to be made to the approaches being used, as well as gives time to plan new goals, if things are going well. Structure also ensures that the therapist and client are staying on track within sessions, focusing on themes that come up for the client, and not being sidetracked by things that may not be as important. As treatment progresses, the therapist is able to shift the agenda setting to the client, to a certain degree. As the client progresses in treatment, they begin to feel more in control and autonomous, and by allowing the clients to set the agenda, within the general structure of the session, the therapist is giving the client practice in making these types of decisions and prioritizing in their lives outside of therapy. As a goal of CBT is to educate clients on being their own therapist once the therapy is completed, this process gives the client practice in doing just that, instead of being guided by the therapist. However, it is necessary to first model how these decisions should be made, which is why the therapist typically sets the structure and agenda in the beginning of therapy.

    Reply

    • Kaitlyn Tonkin
      Sep 23, 2021 @ 13:07:11

      Katie,

      I really liked that you brought up that due to the nature of therapy, and specifically CBT, there might be some negative feelings on the part of the client when discussing maladaptive behaviors or core beliefs like you mentioned. This is where the therapeutic relationship is most important because if someone is feeling shameful about their thoughts or core beliefs, they are going to want someone they trust to be there to understand how difficult the process is. While I had thought about the necessity of the therapeutic relationship in terms of trust, I had not thought about it in this particular way. Thank you for some new insight!

      -Kaitlyn

      Reply

    • Lindsay O'Meara
      Sep 25, 2021 @ 09:40:38

      Hi Katie,

      You’re totally right, the relationship between client and therapist is extremely important when it comes to creating both a safe space for the client and for positive treatment outcomes. I like that you highlighted the importance of session structure. It is easy to go off on tangents and it is important to redirect and keep things moving so that the client can have the most effective outcome in therapy. I also enjoyed that you wrote about the client becoming more empowered, and in turn feeling more confident in therapy and producing better outcomes for themselves. It is so crucial for the client to realize that they are in control and that they are able to work through the problems that they are facing.

      Reply

    • Sergio Rodriguez
      Sep 30, 2021 @ 19:54:27

      Hi Katie,

      I think you made a great point explaining how the relationship between the client and the patient should work on CBT. It is crucial that both parties work together to reach the goals established for the therapy. It is not just the therapist doing all the work and having the client agree to whatever the therapist decides; it is also the patient’s responsibility to play an active role and work to be able to modify his cognitions and behaviors.

      Thanks,

      Sergio R

      Reply

  11. Lindsay O'Meara
    Sep 23, 2021 @ 15:40:24

    1. My understanding is that the therapeutic relationship in CBT is imperative to therapeutic practice. The therapist and client form an alliance where the are both active participants throughout therapy. A strong relationship between client and therapist has a positive outcome on treatment outcomes. Rogerian qualities are important to cultivating a strong relationship with clients. These qualities are empathy, unconditional regard, and genuineness. Certain interpersonal factors also impact the ability to create a strong relationship. They are expertness, trustworthiness, and attractiveness.
    Collaborative empiricism is a research driven, action-oriented therapeutic alliance that uses tests and modifies clients’ thoughts and behaviors. This is the key to creating a therapeutic alliance, and the main factor that focuses on the empirical effectiveness of CBT. It is used to find out what maladaptive conditions and behaviors are present, and then test for their validity. There are three factors of collaborative empiricism, therapist-client activity level, client-specific factors, and conceptualization and treatment.

    2. Having structure during a session helps to keeps the therapy moving forward. It also demonstrates your expertness, trustworthiness, and attractiveness. Structure helps clients to understand CBT and helps the therapist to model the collaboration that is needed in CBT. Staying organized can help to provide direction. The stages of therapy sessions are used to provide guidance by the therapist. There are four stages, pre-session, early session, middle session and late session.

    Reply

    • Sergio Rodriguez
      Sep 30, 2021 @ 19:41:49

      Hi Lindsay,

      I strongly agree with your point of view from the structure during a session. Because the four stages, pre-session, early session, middle session, and late session facilitate stabilizing the treatment goals for the patient. Likewise, most of the patients are having a hard time accomplishing task that are being difficult and following the behavior principles, having a plan or schedule, will help them to know what to expect and what to achieve.

      Sergio R

      Reply

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Adam M. Volungis, PhD, LMHC

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