Topic 4: Psychoeducation & Behavioral Activation {by 2/18}

[Psychoeducation] – Watch MDD-4: Psychoeducation – Therapy Expectations and the Cognitive model AND PDA-4: Psychoeducation – Diagnosis.  Answer the following: (1) How can you adjust psychoeducation of therapy expectations and the cognitive model based on a client’s distress and presenting problems?  That is, what can be said (or done) differently? (2) For psychoeducation of specific disorders, what are some ways you can “normalize” each clients’ experience without alienating them or coming off as lacking empathy?

 

[Behavioral Activation] – Watch MDD-5: Behavioral Activation – Psychoeducation and Introducing Weekly Activity Monitoring Log.  Answer the following: (1) Does this client at least seem moderately engaged and motivated to attempt monitoring his behaviors over the next week? What are the indicators that support your perspective? (2) Based on what you know about this client so far (e.g., information from his assessment and this video vignette), what patterns of behavior do you think warrant follow-up in the next session while reviewing his Weekly Activity Monitoring Log?

 

Your original post should be posted by the beginning of class 2/18.  Have your two replies posted no later than 2/20.  *Please remember to click the “reply” button when posting a reply.  This makes it easier for the reader to follow the blog postings.

65 Comments (+add yours?)

  1. Althea Hermitt- Mcpherson
    Feb 17, 2021 @ 00:52:15

    1. How can you adjust psychoeducation of therapy expectations and the cognitive model based on a client’s distress and presenting problems? That is, what can be said (or done) differently? (2) For psychoeducation of specific disorders, what are some ways you can “normalize” each clients’ experience without alienating them or coming off as lacking empathy?

    Psychoeducation involves providing information, teaching, or giving structured instruction about a diagnosis and presenting problems. It helps to build therapeutic relationships and has an ongoing role throughout different phases of therapy. In both videos, psychoeducation was used to help Mark and Lindsay to gain an understanding of what they are dealing with while also building optimism and motivation. In order to adjust psychoeducation of therapy expectations and the CBT model. Therapists must be mindful of clients’ preconceived notions about therapy and therapeutic approaches due to prior treatments or due to generalization from society. Therefore the therapist would need to address these preconceived notions by exploring what the client and therapist role and expectations are for therapy. Another important component is explaining to the clients about the collaborative approach of CBT and the use of collaborative empiricism to test hypotheses in order to help them to adjust their expectations. Therapists can also adjust expectations of the CBT model by expressing to the client the collaborative nature of CBT, the process of therapy, explain the agenda for sessions, homework, note-taking, the goal-directed nature of therapy, the feedback process, the client eventually being autonomous and the therapist challenging thoughts throughout the process. If the therapist understands the client presenting problems and level of distress this can enable the therapist to consider what method of psychoeducation will be most appropriate for the client to be able to grasp the information. For example, does this client require drawing/ whiteboard or more easily understood language in order to effectively understand the information being presented. The therapist knowing the individual’s level of distress can influence where the focus might be for the session. In Mark’s case he is presenting with depression so educating him about (tracking) behavioral activation can be most important early on in session to help alleviate his level of distress and set him in motion in order to reduce negative behavior patterns, then in subsequent sessions educating him about negative automatic thoughts when he is more able to focus on what that is once his level of distress is reduced. However, from the videos in Lindsay’s case, she was educated about physiological arousal associated with her anxiety because these arousals were the most pressing problem because it landed her in the hospital. This shows that the presenting problem can determine the direction of psychoeducation and what modification might be necessary.

    2. Psychoeducation of certain disorders can help the client to realize that they are not going crazy, because when an individual experiences symptoms of certain disorders, others are unable to relate to their experience, and therefore they may feel alone and scared. Psychoeducation helps them to feel like an expert because they will be equipped with knowledge on what the disorder looks like and how to treat it, which is helpful in the normalization process and reduces social stigmatization. In order to normalize a client’s, experience the therapist must be able to regularize and validate the client’s experience while also remaining empathetic. In the video with Lindsay, Dr. V helped her to understand what she was dealing with, by explaining that anxiety is a normal experience we all have and how it protects us from actual threats and motivates us. He also explained how anxiety can become a problem based on severity and frequency. Therefore, letting the client know that they are not alone with their diagnosis, while also emphasizing positive treatment outcomes can be helpful to the client to remain hopeful in the treatment. In normalizing a client’s experience, the therapist must be mindful not to minimize a client’s level of distress, emotions, or experiences because that can cause isolation and hopelessness in the client or detachment from the therapeutic relationship.

    1) Does this client at least seem moderately engaged and motivated to attempt monitoring his behaviors over the next week? What are the indicators that support your perspective? (2) Based on what you know about this client so far (e.g., information from his assessment and this video vignette), what patterns of behavior do you think warrant follow-up in the next session while reviewing his Weekly Activity Monitoring Log?

    1. The therapeutic relationship seemed very strong as Mark seemed to have a lot of trust in the process and the direction in which therapy was going. With that said I think Mark was very engaged and motivated to attempt the monitoring of his behavior. He listened attentively, nodded with approval, and was very interested in changing his behaviors. He asked a lot of questions about the activity monitoring log and asked clarifying questions when he didn’t understand. He was also attentive to DR. V showing him and explaining how to fill out the log. He was very excited about being able to track it on his phone instead of taking the paper to work. He was focused on the end goal of the activity log and was very excited when he was told it’s not a test and he didn’t need to be perfect about the log.

    2. The patterns of behavior I think warrants follow up would be:
    Marks motivation for change based on completion of the log.
    Mark’s level of social interaction with friends and his wife.
    His isolation/ withdrawal behaviors throughout the week, and what precedes his withdrawal.
    Other activities he engaged in or didn’t engage in.
    Patterns of behavior throughout the week, for example, physical activity, hygiene routines, sleep pattern, chore completion, taking the dog for a walk, etc.
    What activities were pleasurable or unpleasant for Mark and what made him feel accomplished and what didn’t.
    Thoughts and emotions he had throughout the week. Eg. negative automatic thoughts.
    These questions will aid the therapist to focus on target behaviors and possible patterns for change.

    Reply

    • Michelle McClure
      Feb 17, 2021 @ 19:44:48

      Hi Althea! I really liked your post and I thought it was interesting how you included learning theory into your post when you were discussing the different ways that people learn information, like a visual learner would enjoy using the whiteboard and get the most out of information that he or she could see. I thought that was very clever and I think that a good clinician should take into account how a client best receives and processes information. I hope you have an amazing week!

      Reply

  2. EB Elizabeth Baker
    Feb 17, 2021 @ 11:03:48

    [Psychoeducation]
    1) One way we can adjust the psychoeducation aspect of therapy is to use clients’ experiences as examples, the more recent the experience the better. Doing so allows the client to have a better understanding of the terminology as it is applied to their own experiences. Allowing that perspective of the CBT model will not only make the learning process easier, but clients will be able to retain the information better as well. Similar to being a student, course content is received and retained more easily when the professor additionally applies the content to relevant news/experiences/thoughts/emotions of our time. Furthermore, like any learning individual, information can become overwhelming and unclear if the educator does not do a “check-in”. That is, making sure that you are asking clients if they have any questions as well as encouraging them to ask questions and state any confusion. Encouraging questions may allow clients to feel more at ease, that it is okay they do not understand this terminology yet. In turn, the conversation becomes more of a collaborative discussion rather than the therapist just throwing information in the air. Being aware of your vocabulary is also a good way to help the psychoeducation process, as terminology may confuse and overwhelm clients. Of course, we must inform clients of terms we will use throughout the therapeutic experience, but it is helpful to take your time explaining terminology and to remember that you are speaking with a client who may be new to CBT (not to a colleague that speaks the same professional language). Moreover, including diagrams or visual representations helps as well, as it allows the individual to have a pictorial explanation. Sometimes it is helpful to have an extra visual alongside an explanation as clients can follow you step by step during the psychoeducation portion of the session. Lastly, I believe acknowledging clients’ uncertainty with understanding new terms and trying new techniques is extremely helpful. This allows the client to understand that it is okay to be uneasy about new material, but it is also a helpful reminder that they will come to a point where they will understand and may find these techniques useful.

    2) Normalizing symptoms that accompany disorders is extremely important, as you do not want clients to feel that they are an oddity in this world. It is important to speak in a way that does not make the client feel that their symptoms/experiences are inhumane and unnatural, as they may already feel disconnected from others, as well as their selves, due to their condition. By “feeling disconnected from oneself” I mean their cognitions may have interrupted their self-worth, and they may find themselves unmotivated and dispassionate about things that once gave them joy. Validating clients’ thoughts and feelings towards an unpleasant experience are also helpful, as it helps the client understand that it is okay to react, we are all human and may react to specific encounters in specific ways. For example, when Dr. V validated Marks’s response to his friend not returning his call, he said “…If I were in your situation, I’d think and feel the same way.” As in Dr. V’s video, I think it would also be comforting to use the word “we” as it may bring a more compassionate air during the discussion, as opposed to only using “you.” It may allow the client to remind themselves that they are not the only ones who go through such cognitive responses to a distressful situation. It is also important to reassure clients that their response to unpleasant situations is nothing to be ashamed of. The fact that they are currently identifying and discussing some of their maladaptive behaviors is already a huge accomplishment and a step towards progression.

    [Behavioral Activation]
    1) I believe the client was engaged in the process of monitoring his behavior. Throughout the video you can see nonverbal behaviors like nodding, staying attentive, sitting upright, and holding eye contact. These behaviors show that the client is ready to learn about this new technique, and is open to the future benefits of engaging in this activity. In addition to his nonverbal behavior, some verbal behaviors were asking clarifying questions about the assessment/activity and cooperating in those quick “what could you do instead?” exercises. Asking clarifying questions and engaging in these short exercises is another clear sign that the client is open to apply what he has learned to modify his behavior. He was responding and asking his questions in a lively manner as well, and not in a bored “if I have too…” way. It seemed that he was almost excited to try this new strategy to see how his behaviors are affecting his cognition and responses to his environment.

    2) Some behaviors that I believe are worth bringing up during the next session are his thoughts of incompetency when he thinks about work. These thoughts may cause harm to his performance at work, and since he feels he is incompetent, his work quality may start to falter as he might start showing up late for work and ruminate about his poor performance. All of which will significantly affect his depressed mood. Challenging and altering these thoughts will result in him hopefully feeling more confident in his skills, feeling more motivated to wake up on time in the mornings, or potentially searching for a new job. While on the topic, his behavior of feeling rushed in the mornings, since he sleeps sometimes in and does not give himself enough time to get ready for work, is another one to discuss during the next meeting. Although we all understand the pleasure of taking that extra five to 20 minutes of sleep, this can greatly impact our morning routine and consequently make us feel more rushed. The client’s pattern of not giving himself enough time in the morning may stem from his feelings of incompetency in his work skills. His pattern of sleeping in may be a developing avoidance behavior, and if he continues, he may not have the strength to bring himself to get ready for work. As his thoughts of incompetency increase, he will start avoiding the place that causes him to have these negative thoughts about himself. If he is able to identify the reasons as to why he sleeps in knowing that he will feel rushed that same morning, it will help him alter his behavior and maybe alter his schedule. That is, with the therapists’ help, they may work together on putting together a schedule that will help the client get more sleep the night before, and practice mental preparation exercises to get the client more motivated and energized to get out of bed in the morning before work.

    Reply

    • Tim Cody
      Feb 19, 2021 @ 22:04:06

      Hi Elizabeth,
      I think what you mentioned about normalizing symptoms was very wise. It is important for the client to not feel alone with their symptoms, for they may feel that they alone experience these symptoms and no one else can understand them. You mention the therapist should even make comments that with sympathize with them so they can diminish their automatic thoughts that they are alone. They could even disclose their own experiences while dealing with their symptoms, and even share their own ways in which they have over come their own symptoms as well. Disclosing information will allow the client to trust the therapist more, normalize their symptoms, and even build the therapeutic relationship.

      Reply

  3. Anne Marie Marie Lemieux
    Feb 17, 2021 @ 17:19:37

    1)Modifications should be made to educate clients about their diagnosis as well as therapy expectations based on a client’s specific presenting problems and how it applies to them. For example, explaining the positives that anxiety can have when it is adaptive, as well as the biological component of the sympathetic nervous system is appropriate psychoeducation for anxiety. Explaining therapy expectations needs to be done in a comprehensive manner by discussing the outline of sessions, collaboration, being goal focused, treatment planning, and homework in a way that can be understood by the client. This can be done collaboratively by matching to their personality style and by checking for understanding in a non-condescending manner. Describing the cognitive model should also be specific to the clients needs. This was accomplished in the videos by using real examples of how it applies to individual issues. For example, talking to a client with anxiety about the benefits that CBT has shown with exposure therapy versus discussing the process of activation for depression. However mapping sequences of negative thoughts and behaviors can be universal but applied uniquely. Also, by validating their emotions it can normalize their experience and is empathic. For example, when it was stated “If I thought no one liked me, I might have the same response and cry too”. This example shows empathy and builds rapport making it easier to begin challenging the client’s maladaptive thinking.

    1)The client seems engaged and motivated to attempt monitoring his behaviors over the next week. This was observed as he appeared attentive to the explanation of activity monitoring. He was able to identify areas where he would like to see a decrease and increase in his behaviors. He also asked clarifying questions about whether he was to track by the hour or by the task. He asked for more details in regards to pleasure verses accomplishment. He also problem solved the logistics of writing this down while at work. I think reviewing his overall activity, especially his ability to get up and going in the morning would be a good place to start. I would be interested to see his rating scales for pleasure and activities as well as any patterns of withdrawal.

    Reply

    • Bibi
      Feb 18, 2021 @ 12:58:01

      Hey Anne-marie,
      I really liked how you addressed the tone that is used in your explanation of giving psychoeducation. You mentioned using a non condescending tone and I felt like that was really important. This is a collaborative process and I feel like that the tone of voice determines whether it is more of a conversation or a lecture.

      Reply

    • Lilly Brochu
      Feb 18, 2021 @ 15:09:39

      Hi Anne Marie,

      I loved that you pointed out how Dr. V mentioned the adaptive and biological aspects of anxiety. I think that was an important (and clever) way to highlight the adaptive function of anxiety to the client, and how it can be a protective response to our surroundings. It helps to explain a natural cause of the distress that may relieve or normalize the client’s feelings knowing that it is a natural, biological function in the body. Additionally, you pointed out the importance of validating the client’s emotions as it helps the client’s feel more at ease and builds a stronger therapeutic alliance. Thanks for your post!

      Reply

    • Lina Boothby-Zapata
      Feb 20, 2021 @ 22:02:08

      Hi Anne,

      I appreciate the way that you observed how Mark is engaged in the process and all the efforts that he does during the monitoring Log to engage and understand how he is going to make it. It seems simple but you go further with the explanation I explain the complexity. I think, there are no doubts that he is engaged in the process, what I really like with this homework is that the counselor, as well as the client, can begin to identify some automatic thoughts that will be addressed in the following sessions. And Mark also identified them when he said that “in general for him to start activities get complicated, such as the mornings and getting out with his girlfriend, Dr.V as well-identified and stated that “these are some ruminate thoughts around” I think this is a way to confirm that looking for patterns/repetitions are very important

      Reply

  4. Cassie Miller
    Feb 17, 2021 @ 19:25:47

    1. Psychoeducation is very important to the success of the client-therapist relationship, specifically in regards to the client’s level of trust in the treatment being provided (building therapeutic rapport). It allows the client and therapist to work collaboratively and provides the client with the tools needed to increase their autonomy. It is important for the client to be taught the principles behind what they are participating in and the procedures they will be carrying out because it allows them to be the most successful when working independently. These expectations that are set in the beginning of therapy make the client feel more comfortable and can provide some relief for them in regards to the potential for therapeutic success down the road. It is best to prepare this information ahead of time and to not come off as too scripted or rigid as this may cause the client to detach from therapy. Therefore, the clinician must present information in an engaging manner as this is very effective and allows for a good ebb and flow of communication.

    Psychoeducation in regards to therapy expectations and the cognitive model is flexible and can be adjusted based off of client distress. It is very important to adapt these expectations to client-specific examples using the cognitive model, as this will help them connect more to the activity (increasing their engagement). In addition, discussing the client’s presenting problems and concerns is very central to this idea, as these issues are more relevant to what the client is experiencing in the present. It can be important at times to bring up past issues, but for the most part the client will want to discuss what is currently affecting them and it may be a waste of time to focus on some other event with less relevance. In the video, the client was most recently influenced by his friend not taking the time to talk with him or call him back. This phone interaction led him to think “he doesn’t like me,” which in turn made him feel sad and hurt, finally leading to his withdrawal behavior. This withdrawal led him to avoid his social networking and to isolate himself with these negative thoughts and emotions. Dr. Volungis knew this was the pressing issue affecting the client and understood the importance of adapting his psychoeducation of the cognitive model to it, using his white board. This allowed the client to not only feel as though his problems were being addressed, but helped him to further understand the concepts in a more personal way. The client was also involved with choosing his thoughts, emotions, and behaviors, which made this psychoeducation very collaborative. Dr. Volungis also used the language “us” and “we” when going over the model, in regard to what the client was expecting from his friends, to allow for a feeling of closeness and teamwork; instead of the client feeling isolated in this process. A therapist should also be conscious of the client’s headspace in session and what areas of this psychoeducation may be more effective in the moment. For example, since the client was depressed it was more important to focus on behavioral growth areas, such as participating in social activities (behaviors) that would make him feel better. Two of Dr. Volungis’s suggestions for more adaptive behavioral responses were calling a different friend, or attending his social activation meetings instead of avoiding them. Thus, the clients presenting issue, headspace, and focus should all be worked into the meeting and perhaps other important areas could be discussed in a different session.

    2. When using psychoeducation for specific disorders it is important to normalize the experience for the client without leaving them feeling alienated and questioning your level of empathy as a counselor. For starters, the counselor should review that specific disorder, so that they can better fit the client’s experiences to certain aspects of it (since some clients may not experience the same symptoms). Additionally, any resources used should be client specific in so that they match their age group, gender, etc. The information you are using should always demonstrate the most relevance to the client or it will be much less effective. It is helpful to start off discussing the basic principles of a certain disorder, even including certain benefits that it may have. This helps the client understand that what is happening to them is natural and a bodily response to what is going on in their life. Dr. Volungis did this with his second client when he told her that anxiety can be beneficial in the sense that it enhances performance and motivation; which was shocking to her. He also made sure to generalize the physiological symptoms (such as the amount of time a panic attack lasts for, common bodily sensations, etc.), but not her experiences. He used her personal experience of leaving class to explain to her how the misappraisal of her bodily sensations was exaggerating her thoughts and leaving her psychologically vulnerable. This pattern is similar to all individuals with panic disorder and agoraphobia, but not the specific thought patterns she is having, or the behaviors she exhibits. He also let her know that it varies in severity and frequency, which is also demonstrating that he does not think all clients with this disorder experience the same level of it. These details help to demonstrate ways that a clinician can personalize something while also providing a general/normalized overview.

    1. The client does seem moderately engaged and motivated to attempt to monitor his behaviors over the next week. However, it seems as though he becomes more motivated and engaged as Dr. Volungis progresses with the instructions. The instructions become more manageable and understandable as the client asks questions, gets answers, and understands the purpose of participating in an activity that seems rather mundane at face value. He can also be observed rubbing his hands throughout the entire session which does show some hesitancy. However, he does lean in more to Dr. Volungis as he goes further into his explanation and begins to increase his conversation by the end of the instructions. This is also observed in his nonverbal behavior where he is nodding his head and moving his hands in response to Dr. Volungis. His energy seems to increase as well, since he was more slouched in the beginning, but by the end was sitting with more posture and exhibiting more movements. The entire time he is making good eye contact and providing Dr. V with verbal responses which is indicative of him absorbing the information, increasing the likelihood that he will follow through.

    2. Based off of what I know about the client so far, the patterns of behavior that should be monitored in his follow up would be his withdrawal, isolation, and sleeping patterns. I only add sleeping patterns because this can be a direct sign of depressed clients and his sleep regimen had significantly gotten worse since the onset of his disorder (sleeping in later before work). He also has a tendency to withdraw from situations that overwhelm him or when he is emotionally triggered, so it is important to follow up on that. In addition, this withdrawal behavior causes him to isolate himself from social interactions that could have a positive effect on his life. It would be interesting to see how time consuming these behaviors are in his life and when they occur. In addition, the time they were provoked is important to observe, such as whether they were in anticipation of an activity, during it, or during his rumination about the event. His overall activity level, engagement, social experiences, and thoughts and emotions during the week (especially surrounding triggering activities such as his job) should also be observed in detail.

    Reply

    • Michelle McClure
      Feb 17, 2021 @ 19:52:08

      Hi Cassie, I really liked how you discussed the importance of rapport building and trust in therapy. The trust and rapport that is built effects the collaboration that happens between the clinician and the client, it makes sense then that by increasing the rapport and the trust that improves the collaboration and that leads to overall better outcomes at the end of therapy. I also agree that client engagement is an extremely important aspect of therapy, and so the therapist has to find a way to build up that engagement usually by building up the rapport and the trust. I find it interesting how in therapy everything is very interconnected and each piece of the therapeutic puzzle has its own effect on the overall outcome of therapy. I hope you have a great weekend. Stay safe and warm!

      Reply

  5. Michelle McClure
    Feb 17, 2021 @ 19:39:58

    1.1 It is important when meeting with new clients to explain to them how cognitive behavioral therapy works and how you as a clinician are going to run your session and your treatment plan. As a CBT clinician you also have the responsibility to provide your clients with Psychoeducation around their thoughts, behaviors, diagnosis and presenting problems. How a clinician is going to provide that Psychoeducation is going to differ between clinicians with different preferences for interventions and individual style. It is also important as a clinician to be flexible when working with clients and use the interventions that the client will respond better too. A client might and usually does come into therapy with certain ideas or expectations around what they expect from the therapy sessions and from the therapist. The clinician should do their best to clarify the client’s expectations, address the clients fears or preconceived notions if they have any, and to make sure that the client is on board with the session agenda that the therapist has in mind. If the client is particularly distressed about a certain life domain or problem then the clinician should spend some time addressing those concerns and focusing their interventions and Psychoeducation around those identified problems.
    1.2.When working with Mark’s depression and negative self-doubting thoughts, Mark was very focused on his behaviors and Dr. V was able to point out the behaviors and the thoughts that went with them. Dr.V said to Mark that not only did he do these things, these negative behaviors and negative thinking patterns but that “other people do as well”. I think that by saying that “other people do that as well” is normalizing the experience and takes away some of the stigma of going through something alone and that no one could understand. I think that taking an empathetic approach with the client is the best for building trust and rapport but also for teaching the client and normalizing the client’s experience which also are very important pieces of therapy.

    2.1. When Dr. V. introduced the behavior monitoring intervention Mark seemed interested in trying the intervention. Mark was nodding his head and verbally agreeing with Dr. V. which tells me he is at least somewhat interested in what Dr. V is saying. Mark offers “the more the better” when responding to how to fill out the weekly behavior log, which seems to me to be a good sign of interest in the activity.
    2.2. Mark seems like he prefers to withdrawal and isolate himself when he starts feeling emotionally aroused. Mark would like to learn other coping skills besides withdrawing and acknowledges that sometimes he feels like he is trying to run away from his problems and he doesn’t like that. I would ask Mark about times he wanted to or that he did withdraw over the week. I would also be curious about how often he engaged with his girlfriend and any other social experiences ha has had. I would also ask about how much pleasure and accomplishment he receives from his various activities.

    Reply

    • Pawel Zawistowski
      Feb 18, 2021 @ 12:35:31

      Michelle,
      I agree with everything you say. I also think that one thing to keep in mind as a Clinician is that our client may feel anxious, uncomfortable, and uncertain about therapy. Therefore, we should do our best to minimize the mystery of coming to therapy and that will alleviate some of the concerns that a client may have coming in. It will also reassure them that it is not something that will cause them any harm and hopefully will see the benefit of coming to therapy.

      Reply

    • Cassandra Miller
      Feb 19, 2021 @ 13:20:59

      Hi Michelle,

      I really liked your discussion regarding what Dr.V did to normalize the client experience because this is such an important part of CBT. A client should feel understood and heard, while also knowing that they are not alone in what they are going through. The quote that you pulled from the video with Dr. V really helped to demonstrate the point that other people do share a similar struggle and that one person is not isolated in their experience. However, the empathetic approach that you also brought up is what makes the client-clinician relationship so strong. When the clinician uses this approach, the client feels important and listened to, without feeling stigmatized to the label of their disorder. Thus, this balance allows for a comfort in the fact that others also share a similar diagnosis, while also receiving an individualized experience from the clinician (sending the message that everyone goes through struggles that are unique to them).

      I hope you stay safe as well with the snow!

      Reply

  6. Christina DeMalia
    Feb 17, 2021 @ 19:40:03

    Psychoeducation
    (1) As demonstrated between these two different clients, psychoeducation can be tailored to the individual in multiple ways. First the content that is addressed can be specified to the person and their presenting problem. The basic tenants of CBT should always be covered, explaining the relationship between thoughts, emotions, and behaviors. With someone who’s presenting problems are centered around their thoughts, more focus can be put on the nature of automatic thoughts, how they stem from core beliefs, how thoughts effect one’s emotions and behaviors, and how automatic thoughts have the potential to change over time. Someone like the client in the second video, may be focused more on physiological symptoms, and therefore the psychoeducation could be tailored to explain how physical symptoms influence thought and emotion, and therefore behavior. Another aspect of psychoeducation that can be done differently is the language and approach used. In these examples, the first video shows an explanation with broken down language, such as clarifying what reciprocal means in order to make sure the client understood the terminology being used. It also involved more frequent check ins for understanding. For the second client, her knowledge and education level is taken into account, so referencing terminology she might know from school helped to explain the CBT concepts. Essentially, the psychoeducation portion of treatment is the same as any other portion of therapy. Matching can always be used to make sure that the language and mood of the counselor matches that of the client. By adjusting this as well as adjusting the content to the client’s specific diagnosis or presenting problem can help to make the psychoeducation more personalized and impactful.

    (2) In the videos viewed, there were a couple good examples of the way in which the client’s symptoms and experiences were normalized. For the man who was having negative automatic thoughts about himself, this was normalized by explaining that all people have automatic thoughts, and that it is not expected that automatic thoughts will always be positive. However, emphasis is also placed on the fact that for some people automatic thoughts can be more negative than positive. The more these automatic thoughts are negative ones, the more a person can be negatively affected in other aspects of their life. That is when there is a need for a change and improvement in those thoughts. By explaining automatic thoughts in this way, the client is able to understand that he is not alone in his experience and that a lot of what he experiences is actually considered normal. However, the client’s problems are not minimalized. He is also validated in that his automatic thoughts have reached a point of causing distress. For the women with agoraphobia, her experience of anxiety and somatic symptoms are normalized. It is explained that in adaptive functioning, those responses are actually essential evolutionary adaptations. Her experiences are made normal by explaining that everyone experiences anxiety, and that sometimes anxiety can be really useful, such as the stress you feel about a test that gives you the drive to study. By explaining that her body’s responses were not necessarily bad, the focus could be placed on her maladaptive interpretations of her physical symptoms. The difficulties that she is experiencing are validated rather than minimalized, but at the same times some of her experiences are normalized in order to make her feel less alone or isolated in her situation. This same pattern can be followed for any client with any diagnosis. The experiences they have can be normalized with in the context of other people and normal functioning. In order to show empathy the counselor can offer that context to normalize their experiences, while still acknowledging how their individual experiences are distressing and how therapy can serve as a way to improve some symptoms.

    [Behavioral Activation]
    (1)
    This client does seem motivated to attempt monitoring his behaviors thorough this activity. He does express slight hesitation at the thought of having to pull out a piece of paper during work to document things. However, when a solution is presented: taking notes in his phones notepad, he is relieved continues to seem onboard with the assignment. When asked how he would feel if he would be able to change some of his behaviors, the client perks up and says “I’d feel pretty good, I think,” and continues to talk about how he would feel better if he could get past his withdrawing. The client seems to pay close attention to the explanation, is engaged and asking questions, and even though he seems like he might think there will be a decent amount of work involved he says “I just gotta do it.” To me, he appeared to understand that if he wanted to reach the end goal of changing his undesirable behaviors, this was an important step to getting there.

    (3) One area that seems like it warrants a follow-up is the way the client seems to get worked up and anxious before his date. Because he is so worried about things like being on time and finding parking, he is making something that is supposed to be a pleasurable activity into something that is stressful and negative for the first half. By following up on this, the client could recognize other times when he has had similar experiences, and start to trace the pattern. From there, he could recognize his tendencies towards dichotomous thinking, believing that something will either go well or poorly and nothing in-between. By being able to recover more quickly from a rough start, the client can get more enjoyment and pleasure out of his activities. Another point that warrants follow up is the comments the client makes about getting laundry done. He explains that he feels good about himself and like he’s getting something done when he accomplishes it, but has a hard time getting started. The feeling of accomplishment that he feels is something to work for, which means that focusing on how to get past that difficult initiation will be important for the client to be more productive.

    Reply

    • Lina Boothby-Zapata
      Feb 17, 2021 @ 20:29:31

      POST

      1.Psychoeducation

      a. The vignette provided by Dr. V with his two clients Mark and Lindsey illustrates the integration of Psychoeducation of therapy expectations and cognitive model. Dr. V demonstrates in his vignette how we can integrate these clinical concepts into practice to create adaptative behaviors, thoughts, and feelings. For example, in the PDA-4 video with Lindsey first, Dr. V psychoeducates his client; he explains to Lindsey her diagnosis and presenting problems, and he creates expectations and goals. He explains anxiety in a “normal range,” stating that we all have anxiety because this is an essential biological response. However, Lindsey becomes abnormal and impairs her life. Lindsey stops going alone to public places, and she has a hard time staying in class. Second, Dr. V educates his client about how a primary biological response becomes abnormal, presenting panic attacks. Third, he educates his client with the explanation of panic attack symptoms and Dr V. proposes to the client a plan about what they are going to do in a collaborative process to break those cycles or, in other words, to break that chain of automatic thoughts that maintain these behaviors.

      In summary, psychoeducation of therapy expectations and cognitive model is adjustable according to the client’s presenting symptoms and diagnosis. This is why we need to prepare before the sessions to provide psychological explanations to the client. In a collaborative process, the client will produce new behaviors, thoughts, and emotions with the counselor’s support. I am just concerned with clients that they don’t have access to this level of understanding about their symptoms, disorders, and differences between malfunctioning and normal functioning. What happens when the client has a low level of education such as primary elementary and can’t process or understand it? How we approach them and explain this complex theory? What about for children? How do we approach to them?

      b. One of the main goals of Psychoeducation is that after explaining what is happening to the clients, the client will have more optimism, meaning that there is a chance to improve quality of life. Most of the clients probably don’t have any knowledge about psychotherapy and psychopathology. They have symptoms and suffer the diagnosis but don’t have a deep understanding of what is happing. When the counselor provides the client with this information, it could reduce anxiety and increase optimism for their wellbeing. Also, when the therapist provides this information helps the client to normalize his symptoms, meaning that he is not alone in the world, it is saying, “this happen to people, is not only you, this is what is happening, and this is what we are going to do”. Furthermore, this psychoeducation and normalizing symptoms can take away the feeling of hopelessness and have catastrophic thoughts related to his symptoms, such as “I am going to die.”

      Another benefit is that “normalizing” the client’s symptoms creates a sense of “collaborative work,” meaning that we will tackle this together and at the same time increase confidence and build positive rapport towards the therapist. For example, Dr. V’s PDA -4 Psychoeducation video helps us understand this process. He explains to Lindsey about her Anxiety is a normal experience because it protects us from actual threats and motivates us to perform tasks. Hence in those circumstances is a good thing to have anxiety. This is a biological response that protects us from harm. Then, he states if anxiety is too high, then it is a problem. In this case, Lindsey’s body presents a high rate, dizziness, and light flashes. Again, verbalizing and describing the client all of this situation gets a sense of “it is okay, we can tackle this together, it is not too bad, I know what I am talking about it, and an expert”. Then the client can breathe and focus on the therapy work.

      2. Behavioral Activation

      a. MDD-5 video about Behavioral Activation Mark is engaged and motivated in general during the sessions. The client asks questions, and he expresses interest and understanding during the psychoeducational part and the monitoring log. I see beneficial is the explanation of the monitoring log. This is an excellent strategy to engage the client with the therapeutic process. Monitoring log could be perceived as a simple homework to do, and a little bit bored as well; however, providing the client the explanation of how to do it, the purpose, the expectations, and how important it is to incorporate in the clinical process gives another sense to the homework. Furthermore, it gives a new understanding of how important it is to complete it. I see the monitoring log as an opportunity to trace treatment goals and identify automatic and core beliefs. Simultaneously, as Dr. V explains, behavioral activation’s primary goals in CBT are to reduce negative reinforcing behavior patterns while increasing positive reinforcements behavioral patterns.

      Indicators to support this perspective are when Dr. V explains to the client about the monitoring logging goal; this activity is hour by hour, monitoring the more and specific the better. Mark is all into trying to understand the homework. How do you feel if you could change some of your behaviors? Another element that Mark is engaged in is the questions that Dr. V is asking him, what is less challenging, what actions you would like to increase or decrease? What activities would you like to do? Mark knows what he wants to ideally perform in daily life and answers, getting more active with his girlfriend, walking the dog, and going out with friends. Mark is open with his counselor and disclosed information about his feelings, thoughts, and behaviors.

      a) Mark identifies his own challenges and pattern of behaviors, he actually communicates to the counselor what is uncomfortable with him and what he wants to modify or change, in terms of behaviors. In this particular weekly activity monitoring log Marks expresses his challenge with waking up early. He states that he starts works at 9:00am and he wakes up at 8:00am. He doesn’t have time more than for a shower and get dress. He expresses that his ideal is 6:30am and then he can have breakfasts and take his dog out. He also struggles with his girlfriend, stating that it is a little bit funky just to coordinate logistics. In general, Mark identifies that it is difficult for him to get start activities such as; waking up in the morning, going out for dinner, doing his chores at home, laundry, dishes, etc. Also, Dr. V does in MDD-6 vignette he stated that this could be related to anxiety and ruminating thoughts. These activities will be ideal but also the enjoyable activities that he would like to do for next weeks, such as taking the dog out to the park or meeting with his friends.

      Reply

  7. Alexa Berry
    Feb 17, 2021 @ 21:38:07

    1.
    Psychoeducation is an important factor in the progression of therapy because it is crucial for clients to learn how and be able to apply cognitive-behavioral skills independently, when the clinician is not present or following the end of therapy. Psychoeducation looks different during the early stages of therapy and in later sessions when therapy progresses. Additionally, psychoeducation of therapy expectations and the cognitive model can look different depending on a client’s specific presenting problem or distress levels. Some ways these expectations for psychoeducation can be adjusted are by using examples that are specific to their presenting problem because it is more relevant to the distress they are experiencing. When explaining the model to them, it shouldn’t always be one sided where the clinician does all the talking. Rather, when explaining the interaction of thoughts, emotions, behaviors, etc. therapists can ask their clients questions about how these specific factors relate to them and their experience. This also varies depending on their level of understanding of the cognitive model, and their awareness of their own thought and behavior patterns. More specifically, if you are treating a client with anxiety you can provide them information on their anxiety and go through therapy expectations and the cognitive behavioral model for what this would look like for clients with anxiety. This could entail describing common thoughts associated with anxiety disorders and corresponding behaviors and emotions. The CBT model can be conceptualized and explained with specific disorder details and behavioral occurrences, such as when an individual experiences panic attacks (explain thoughts, behaviors, emotions associated with panic attacks). If a client is less aware of their own experiences, a clinician can also go through the CBT model with common thought and behavioral patterns to their specific disorder, just not the clients specific thoughts/behaviors/emotions (i.e a depressed patient isn’t aware of their own behaviors and thoughts but can conceptualized the CBT model based off of “typical” depressed characteristics).

    It is also important to educate clients about their specific condition and explain how CBT can help to both reduce their distress and improve their quality of life. Most clients feel some relief when they are informed of their diagnosis because it puts them closer to understanding their distress. Some ways to normalize their experience is by providing them with information on common symptoms, incidence/prevalence rates, and possible etiological factors. This information can help clients put into perspective that other people experience the same things they are experiencing and it is not abnormal from a clinical perspective. It can help for clients to know that you have treated other people with similar presenting problems because it can build their confidence in the idea that therapy will work while also reassuring them that other people have had similar experiences. Using psychoeducation to give clients information on their problem can also contribute to the therapeutic relationship by showing clients that you are equipped to handle the problem and are optimistic about the outcome of therapy for them. While it is important to normalize clients experiences, it is also important not to do too much of this, because it can result in them thinking they’re just another client, when in reality their unique circumstances are related to their distress.

    2. In his session where he is informed of and introduced to a weekly activity log, Mark does seem to be engaged and motivated to attempt monitoring his behaviors over the period of a week. During the psychoeducation component, Mark asks various clarifying questions and makes statements about his desire to increase certain behaviors, as well as statements about how he feels upon completing tasks. Through asking questions, it is clear that Mark wants to have a good understanding of how he should be completing his activity log. In his statements, Mark expresses a clear desire to engage in more adaptive behaviors, or behaviors that typically bring him pleasure that he has withdrawn from. Based on what we know about Mark from his assessment and this clip, it is important to evaluate behavior patterns related to his social engagement and work-life at the next session. In his initial session, Mark expressed that he uses withdrawal as a coping mechanism and does not engage socially with his friends or acquaintances as often as he used to. Additionally, Mark expressed concerns with his productivity at work, and again in this session expressed that work is a big stressor for him. Based on this information, it is important to assess whether Mark has made any progress with social engagement (i.e calling a friend, going out with his wife) and to further assess Mark’s productivity through his activity while he is at work. Another concern that arose in this session is Mark’s ability to engage in daily tasks like waking up early for work and doing the dishes, so this also warrants a follow up in the following session.

    Reply

    • Lilly Brochu
      Feb 18, 2021 @ 15:08:10

      Hi Alexa,

      It is important that the client is able to feel comfortable and hopeful that their therapist is able to guide them in the right direction towards successfully completing their goals in therapy. Psychoeducation allows the therapist to further the client’s understanding of their diagnoses and presenting problems as well as building rapport, mutual respect, and trust within the therapeutic alliance.

      Moreover, it is important to highlight that an environment that causes a lot of Mark’s distress is at work. I think it would be a great idea to check in with him to see the levels of pleasure and achievement he felt in the activities in that setting compared to other settings to see the disparities between the two. Great post!

      Reply

    • EB Elizabeth Baker
      Feb 20, 2021 @ 15:09:36

      Hello Alexa!
      I liked how you used specific examples using anxiety to explain how to change expectations of psychoeducation. We could also see how, in Marks’s case, how he was understanding terms and concepts of psychoeducation as he was nodding and able to give his own personal examples. Not only do I think that this is a good way to psychoeducate clients, but it also increases clients’ self-efficacy to be able to understand and apply the terms to their own behaviors. This way, not only does it make the learning process more personable, it allows the client to be able to analyze and modify their behaviors (including thoughts and emotions) outside of the session.
      I also like how you mentioned educating them on their diagnosis. I know this is not an ethics class, but I remember one of the ACA codes said to not inform clients of their diagnosis if you believe it will cause harm to the client. I think it is so important to notify clients of their diagnosis, and although it may increase negative affects within the client, it allows the client to become more aware of their behaviors (again, including thoughts and emotions) and to learn more about their diagnosis and relating symptoms with their clinician. This conversation can hopefully ease some of the client’s distress upon learning about their diagnosis.

      Reply

  8. Brianna Walls
    Feb 17, 2021 @ 21:46:36

    1. Depending on the client’s level of distress and the problems they present will determine how the therapist should adjust the psychoeducation of therapy expectations and the cognitive model. Firstly, it is important for the therapist to educate their clients about their specific conditions and how CBT can reduce their distress and improve their quality of life. This will give the client hope to remain in therapy and essentially give it a chance. This information can help build optimism and motivation within the client. Depending on your client it is important for the therapist to accommodate their learning preferences. It is important to communicate in a way that the client can understand and be engaged. It is also important to communicate to your client that you two will work collaboratively throughout therapy. Based on the client’s past experiences with therapy of their views on therapy the therapist should help instruct them on how CBT is supposed to work. The therapist should review symptoms, set an agenda, and review and assign homework when acceptable. Further, the therapist and client should come up with a clear goal in mind for therapy. This goal can be changed and/or modified as therapy progresses. Also, it is important that the therapist lets the client know that as therapy progresses the client should be able to rely less on their therapist and use CBT skills at home. In addition to all this, the CBT model should be discussed early on in therapy as it sets the foundation for how the client’s problems will be conceptualized and treated. Further on in therapy relationships between triggering events, autonomic thoughts, emotional and physiological responses, behaviors, and associated outcomes can be discussed with the client. In conclusion, all of these steps can be rearranged and modified based on the client’s level of distress, education, and presenting problem(s).
    2. One way you as the therapists can “normalize” your client’s experience in terms of psychoeducation of specific disorders is by discussing the common symptoms of their disorder with them. This may help the client become more aware that the symptoms they have been having are from the disorder, and not because they are “crazy” in addition they may feel a sign of relief from hearing this information from their therapist. Another way the therapist can help their client “normalize” their experiences is by sharing incidence/prevalence rates of the disorder. This may help the client realize that they are not the only ones suffering from the disorder and that there are many people like them who have been diagnosed as well. In addition, the therapist may share possible etiology factors of the associated problem(s) with their client. This may help the client become more aware of how they developed the disorder, and that it wasn’t their fault. Further, the therapist should disclose to the client that they have worked with other clients who have been diagnosed with the same disorder or similar problems and there have been positive outcomes. This will help the client remain hopeful. Moreover, the therapist should disclose that therapy may not fully “cure” them but that it will help. However, when the therapist is helping the client try to “normalize” their diagnosis it is important that the therapist does not minimize their client’s unique experiences that are related to their distress, the therapist has to make sure they balance normalizing the client’s diagnoses.
    1. Based on the video I watched Mark seems moderately engaged and motivated in attempting to monitor his behaviors over the next week. Some indicators of this are how he asked a lot of questions that were related to the weekly monitoring log. In addition, Mark nodded his head a lot and made eye contact with his therapist which indicated that he was paying attention to his therapist and was engaging in the conversation. Mark seemed excited to try the weekly activity log and knew what behaviors he would like to change and work on. I also think he felt some sort of relief when the therapist told him that if he missed a day it wouldn’t be the end of the world and that it didn’t have to be perfect. All in all, I think Mark was engaged and motivated to attempt monitoring his behaviors over the next week.
    2. Based on what I know about Mark I believe there will be a few patterns of behavior that the therapist and Mark should follow-up on. One behavior might be the tasks he was asked to do at work because he mentioned that they have been taking twice as long to do and it takes him a lot more effort than usual. Another behavior they should look at is his sleep. He mentioned that he has no desire to wake up and that he has been sleeping an hour or two later than usual. Another behavior they may look at is walking his dog. He said he used to look forward to bringing his dog to the dog park but recently he has little to no desire to do this. In addition, they may look at if he has been spending more time with his girlfriend and friends. All in all the therapist and Mark should focus on withdrawal, sleeping patterns, and energy/desire.

    Reply

    • Tayler Weathers
      Feb 18, 2021 @ 12:07:22

      Hi Brianna! I love that you bring in the goals for psychoeducation. I think that making the knowledge you’re teaching a client “useful” is a really great way to motivate them! It makes me think about all the times I sat in calculus, thinking “when am I ever going to use this?” Making skills more immediate and practical is always a good way to boost interest and retention. I think repetition of this would be important, even after the psychoeducation piece is done. A key in education is to not lose the thread of “why we’re here,” so that every task feels as relevant as the psychoeducation. Plus, it sets up an expectation of client work, which is important!

      Reply

  9. Yen Pham
    Feb 17, 2021 @ 22:30:00

    1.Psychoeducation

    1.a. How can you adjust psychoeducation of therapy expectations and the cognitive model based on a client’s distress and presenting problems? That is, what can be said (or done) differently?

    We can modify psychoeducation of therapy expectations and the cognitive model based on a client’s distress and presenting problems by some ways. First, soon after the intake session (and in some cases during the intake), we need to discuss what clients should expect while participating in CBT. This discussion should also include the cognitive model, including its relation to their presenting problems and diagnoses. Additionally, within a few sessions into therapy, it also advised to review your case formulation and treatment plan with your clients. Dr. V explains that it is a good time to segue into providing some psychoeducation for the cognitive model after reviewing expectations for CBT. This information must be reviewed early in therapy because it sets the foundation for how clients’ problems are conceptualized and treated.
    Second, we should introduce the key cognitive model terms and their meanings. Learning the cognitive model is sort of like learning a new language for some clients. Using CBT language naturally provides a new and different lens in how the self, others, and world are viewed. Dr. V suggests that we should pay attention to a key theme that should always be covered is explaining the relationship between triggering events, automatic thoughts, emotional and physiological responses, behaviors, and associated outcomes. It is useful when we include a review of reciprocal determinism if we think our client has poor awareness between how thoughts, emotions, and behaviors influence the environment, which in turn precipitates and exacerbates your clients’ distress.
    Third, we consider to provide visual examples of the Reciprocal Cognitive-Behavioral Model with handouts or using a whiteboard in our office. We can make our own modifications so that they are more appropriate to our clients’ needs. Dr. V claims that we should use an example specific to our clients’ presenting problems. That is often most effective because it is more relevant to their own distress. For example in the video MDD-4, Dr. V shows us the example of his client who is distress because his friend, George did not pick up his call. Besides of feeling hurt, this client was thinking that maybe George doesn’t want to be friends with him. Maybe George doesn’t like him anymore. Dr. V also guides and applies the concepts of CBT on his client’s presenting issue to challenge his client modifies his thoughts.

    1.b. For psychoeducation of specific disorders, what are some ways you can “normalize” each clients’ experience without alienating them or coming off as lacking empathy?

    There are some ways that we can normalize each client’s experience without alienating them or coming off as lacking empathy.
    First, we should give clients a diagnosis of their problem. Dr.V indicates that most clients often feel at least some relief when informed of their diagnosis because it is a step closer to understanding their distress. We should provide clients a psychoeducation on common symptoms, incidence/prevalence rates, and possible etiological factors of associated problems can help normalize their experiences. For example, in the video PDA-4: Psychoeducation- Diagnosis, Dr. V talked to his client that “anxiety is a normal experience that all of us have. In fact, in a lot of ways it’s evolutionary. Anxiety is a good thing because it protects us from actual threats. In other words, if something harmful is going to happen- a legitimate harmful experience- we start to experience those symptoms, and that helps protect us….Where anxiety becomes a problem is where it can really vary in severity and frequency. If we have too many moments in our lives with extreme anxiety that can result in poor task performance.” Dr. V believes that although we cannot ethically guarantee that therapy will fully “cure” them, it is also prudent to assure your clients that you have treated other people with similar diagnoses and problems with positive outcomes. Clients are often relieved to hear that you do not think they are “crazy” and that many other people have similar experiences.
    Second, we should consider being careful with balancing normalizing clients’ diagnoses and problems and not minimizing their own unique experiences related to their distress. Dr. V explains that if we overcompensate with normalizing, this can actually hurt rapport (“I’m just another depressed client.”) and possibly communicate that treatment is not necessary (“If so many other people have what I have, why bother?”).
    Third, we should consider providing or drawing a diagram of the CBT model specific to our clients ‘diagnoses. We should use the general cognitive model as a foundational concept. We can use a whiteboard to explain the specific diagnostic components related to the interaction of their thoughts, emotions, physiological sensations, behaviors, and environmental influences.

    2. Behavioral Activation

    2a. Does this client at least seem moderately engaged and motivated to attempt monitoring his behaviors over the next week? What are the indicators that support your perspective?

    I see this depressed client, he seems moderately engaged and motivated to attempt monitoring his behaviors over the next week. There are some indicators that support my perspective. First, this client is ready moving on to new intervention i.e., homework or self-assessment. There is a good therapeutic alliance between him and his therapist. Thus, he has a motivation to change some of his behavior patterns throughout the day. For example, he wants to be present with his girlfriend and going out with her. Whether it’s bringing the dog for a walk together or going out to eat together, going out on double dates. He is willing to take the therapist’s suggestion and guiding on his self- assessment on his daily activity as to write
    down the time he woke up, then he took a shower, eat breakfast, or whatever it was.

    2.b. Based on what you know about this client so far (e.g., information from his assessment and this video vignette), what patterns of behavior do you think warrant follow-up in the next session while reviewing his Weekly Activity Monitoring Log?

    One of the most important initial goals for depressed patients is scheduling activities. Most have withdrawn from at least some activities that had previously given them a sense of achievement or pleasure and lifted their mood. And they frequently have increased certain behaviors (staying in bed, watching television, sitting around) that maintain or increase their current dysphonia. They often believe that they cannot change how they feel emotionally. Helping them to become more active and to give themselves credit for their efforts are essential parts of treatment, not only to improve their mood, but also to strengthen their sense of self-efficacy by demonstrating to themselves that they can take more control of their mood than they had previously believed. Therefore, I think warrant follow-up in the next session while reviewing his Weekly Activity Monitoring Log, we should consider some patterns of behavior such as we can ask the client to do self- monitoring on his social activities such as going out with friends, and girlfriends. We also ask the client to write down his thought, i.e., thought record and mood diary.

    Reply

    • Beth Martin
      Feb 18, 2021 @ 00:46:51

      Hi Yen!

      I really enjoyed reading your post – it was very thorough! I particularly liked the second point you made regarding normalizing the client’s experience, as it wasn’t something I’d necessarily considered. I think it’s extremely important to remember that we can definitely go too far with normalizing things, and there’s a fine line to walk to make sure that we normalize without discounting. Making a client feel like we don’t take their issues seriously would be a great way to destroy the therapeutic alliance before it’s even created.

      Thanks for posting!
      Beth

      Reply

    • Lina Boothby-Zapata
      Feb 20, 2021 @ 22:04:22

      Hi Yen,
      I am glad the way that you provided arguments about the importance of the monitoring log, including the lifting of their moods trying to engage them in activities but also providing them with some sense of self-efficacy and control of their moods and behaviors. One element that I have struggling about the monitoring logs and homework throughout all Therapy sessions is that CBT can easily become a recipe book. Meaning that if your client has certain symptoms, then you can go to the CBT Manuals and see which homework works for the client, also is like when you go to the Doctor made a diagnosis, and prescribes some medication. Another challenge that I have is during Mark and Dr.v sessions he doesn’t ask Mark’s personal history. With my experience DCF assessments are in the direction of asking people about their childhood and adulthood history, most of the time create a positive rapport with your client and allow you to understand why your client is for example; neglecting his/her children. Anyways, want to put these thoughts out there…

      Reply

  10. Abby Robinson
    Feb 17, 2021 @ 22:32:54

    Psycho-education
    1. It is important to explain psycho-education to the client because it allows them to actually see and hear why they are going to be going through this process of CBT. This helps them understand the reasoning for their thoughts and behaviors and also helps them understand the techniques to help cope with the maladaptive-ness of their behaviors. Also, psych-education helps build a relationship with the client because the client can see that their therapist is knowledge, has good intentions and “knows what they’re doing”. It is the therapist’s job to adjust their psycho-education with clients. This is because every client will obviously have different presenting problems and adapt differently to beginning therapy. Dr. V showed that he adjusted the psycho-education between both his clients by using visual aids, explanation of terms, and also used the client’s personal stories to adapt the education specifically to them. This seemed to really help his clients understand why and where their thoughts and behaviors are coming from. Using their own personal situations to explain their diagnosis builds the relationship as well. It is also important to read the room and read the client’s non-verbal behaviors when using psycho-education. In the videos, both clients seemed to be aware and understanding of it, but other clients may get overwhelmed and flustered with a lot of information being given to them, in which case the therapist should recognize that.
    2. It is helpful for the therapist to make the client feel “normalized” when they are being diagnosed with a certain disorder. This is important because it can help with the client’s drive to change, help them understand why they may be feeling/acting in a certain way as well as help them understand the expectations for their goals. The therapist can help the client with this by informing the client what this diagnosis is and what the symptoms entail. This helps the client realize their symptoms fit into the category. Also the therapist can use relevant information that pertains specifically to their client; for example “you feel like you are having a heart attack during this time because you are having a panic attack”. Additionally, the therapist can help “normalize” their client’s diagnosis by using reference to others to help them feel like they are not alone in this. By using psych-education to explain to the client that this is what happens/why this happens for certain disorders, the client will understand that this is a situation that has happened to others before and the therapist knows how to approach it properly.

    Behavioral Activation
    1.After watching this session, it seems that this client does seem motivated and engaged to complete the weekly log for his behaviors. This session, the client is engaged with Dr. V, asking questions about how to fill out the sheet and what activities he should be writing in. This shows that he is engaged in this assignment and wants to complete it ‘properly’. The client is using head nods and “mhms” to show that he understands the situation. Also, when Dr. V asks about things the client would like to work on and future goals, the client engages in this conversation with hope and shows he understands the behaviors and thoughts are becoming maladaptive to him and wants to change them.
    2.I think that in the follow up for the next session reviewing the activity log, certain patterns behaviors to talk about are his thoughts, feelings during work. As they note this can be a tricky time for him and this is where he spends a good portion of his day. Also, I think following up on doing more simple activities, as the client mentioned taking his dog for a walk with his girlfriend. The client seems to want to work a lot on being withdrawn from his social life and following up on those kinds of activities might help him start to plan out the goals for the next homework assignment.

    Reply

    • Beth Martin
      Feb 18, 2021 @ 00:43:21

      Hi Abby!

      I think you make a great point on following up on how he feels both at work and during an activity he previously enjoyed – I hadn’t considered looking at both the positive AND negative. I’d be really curious to see if he used the note app that Dr. V recommended, or if the stress of using the paper form at work contributed to his feelings/sense of accomplishment. I think looking at the positive action of walking his dog could be a great “tracker” for him, something that they could follow up with each week to see visible progress, that he has a baseline for and can remember what a 10 feels like.

      Thanks for posting!
      Beth

      Reply

    • Tayler Weathers
      Feb 18, 2021 @ 12:09:39

      Hi Abby! I think you’re right about Mark’s feelings about work. As we talked about in 504, work is a huge part of a person’s day and life, and so having that feeling of burden on him probably makes his days seem more negative than they might otherwise. Plus, work has the clear opportunity to be fulfilling and purposeful, where sometimes interpersonal relationships (like his girlfriend) might be more easily mentally discarded. He seems to care about those, but work might be a great place to start!

      Reply

    • Christina DeMalia
      Feb 19, 2021 @ 15:26:29

      Hi Abby,

      I really like the point you made about working on how the client feels and what he does while at work. He seems to talk about the good and bad of his social and home life, but so far has only seemed to share negative experiences from work. As you pointed out, he spends the majority of his time each week. I think this is a huge thing that can be easy to forget about with clients or even with ourselves. When work is just seen as something to get through, the client might not spend as much time reflecting on it as he does with things like his friends, girlfriend, or dog. However I think if he were to spend some time thinking about his experiences at work, he might be able to change his thoughts to be more positive about the work he does accomplish and less focused the stress it may cause. By having a better outlook on the thing he does for 8 hours a day 5 days a week, a huge portion of his life may start feeling better. That shift in thinking and increase in positivity could have an effect on his overall depression and his functioning in other areas of his life.

      Reply

  11. Pawel Zawistowski
    Feb 17, 2021 @ 22:42:13

    1.
    Going over psycheducation topics such as therapy expectations can help the client feel more comfortable about coming to therapy and minimize the mystery of therapy and setting structure. It allows the clinician to set an agenda and layout a general idea of what therapy will look like. Based on the client’s level of distress and presenting problems, we can adjust psychoeducation to match their needs. We would provide information that is relevant to their presenting problems. For example, if the client is experiencing substance abuse problems, we would make sure that their expectations of treatment goals, direction, homework, etc., are clear and they understand the level of collaboration that is expected of them. Also, they will know ahead of time that their way of thinking and behavior will be challenged. The client should be made aware that the clinician will be taking notes, and they are also encouraged to take them. Additionally, they are free to ask questions and have a general understanding of session structure. They should also understand that at times they may experience distress before it is reduced when they are being challenged. It is not always the case, but it may occur and they should understand that it is a challenging process to challenge existing ideas and behaviors. The client should expect that one goal of therapy is to nurture independence and that they will rely on the therapist less and less as they progress through therapy. Lastly, the cognitive model should also be reviewed early in therapy as it provides conceptual ideas of how the client’s problems will be treated. When presenting cognitive treatment tools to the client we should consider their triggers, potential automatic thoughts, physiological responses, behaviors, and associated outcomes. Providing this information to the client will provide the client with an understanding of how CBT will help them with their presenting problems.

    2.
    When providing psychoeducation of specific mental disorders, we have to be aware of how we present this information. We should normalize each client’s experience without alienating them or coming off as lacking empathy. Most of the time, our clients will feel a sense of relief when they are informed of their diagnosis because it provides insight of what is causing them distress. We can normalize their experience and diagnosis by providing common symptoms that people experience, as well as the incidence and prevalence rates. However, we should be careful when we generalize and not minimize their unique experience. They should also be aware that we cannot fully cure their diagnosis, however positive outcomes can be achieved with treatment. Clinicians can successfully do this by providing the client with accurate and honest information about the client’s presenting problems and diagnosis.

    1.
    Yes, I believe Mark is engaged and motivated in the attempt to monitor his behavior. He gave Dr. V the verbal “okay” in agreeance that he will attempt this homework. Mark also nodded and appeared to be actively listening as Dr. V was explaining the expectations to Mark. I do not think that it is something that Mark may be very excited about, however, I do believe he sees the value and potential benefit of self-monitoring his behaviors. Mark appears to me as a person who is self-aware and can provide insightful feedback about his experience so I believe some of the motivation will come from his natural ability to analyze encounters that he faces on day-to-day basis.

    2.
    I believe some patterns of behaviors that warrant follow-up in next session while reviewing his weekly activity monitoring log is to see if he has had any cognitive discrepancies such as jumping to conclusions or catastrophizing. I also think it would be important to assess if he has been withdrawing, have him reflect on how it effects his marriage, as well as what kind of coping skills he is using to regulate emotions.

    Reply

    • Anne Marie Marie Lemieux
      Feb 19, 2021 @ 13:41:15

      Hi Pawel, I think you made an important point about preparing clients that symptoms may get worse before they get better as they begin challenging their automatic thoughts and behavioral responses. I am personally a little nervous about the idea of telling someone that is already in distress that symptoms may amplify as they get better. I believe the goal would just be to be focused on the big picture and stay optimistic and future oriented. I also liked your phrase that “nurture independence”as it describes the care that is involved in guiding a person through the process while empowering autonomy. Thanks for the post!

      Reply

    • Cassandra Miller
      Feb 19, 2021 @ 14:38:42

      Hi Pawel,

      I agree with your reasoning for why Mark seems engaged to attempt to monitor his behavior. I also noticed his head nodding and active listening with Dr. V. I really liked that you brought up the idea that he has a natural ability to analyze encounters that he faces on a day-to-day basis as I noticed this a bit too; such as when he comes to conclusions about why he is not doing certain things (ie. his trouble initiating activities). However, I would be curious to ask Dr. V if this is a result of insight skills that he may have developed from doing prior therapy with him, or if he has naturally good insight? It is also good that he does not struggle with completing activities as much once he gets started on them because this skill will increase the likelihood that he can experience more success with tasks once he starts them (likely increasing self-efficacy and self-esteem).

      Reply

  12. Beth Martin
    Feb 18, 2021 @ 00:40:42

    Psychoeducation:
    Depending on a client’s distress or presenting problems, psychoeducation of therapy expectations and the cognitive model may need to be delivered differently. Psychoeducation refers to the process of informing a client about the therapy process, their symptoms, and of any diagnoses they can get. Therefore, there’s a lot of wiggle room on how it can be delivered, as there’s a vast array of symptoms, diagnoses, and preconceptions about how therapy should go. It should be tailored to match how a client is presenting, and the information they are giving, but should also always cover the basics of what CBT is, including the structure and things like homework being crucial. After that, target misconceptions about therapy (e.g., the client isn’t going to be lying down talking about their mother), and seek to educate the client on how therapy can help with their presenting problems. For example, the client in the second video seems to be interested in the physical sensations she is experiencing. Explaining how mental illness (anxiety etc.) can have physiological symptoms would be a great way to tailor the education to her particular case. Psychoeducation, when tailored to the client, has the added benefit of making the therapist appear expert AND that they care, helping soothe any concerns about therapy and directly addressing the client’s symptoms, rather than just reeling off a pre-written spiel.

    One way to normalize client’s symptoms and experiences, without coming off as patronizing or minimizing, is to verbalize the process as a collaborative one. Using “we” is a great way to go about this; when a therapist is going over what will be done in sessions, saying “we will be tackling xyz” as opposed to “you will be doing this” may help prevent the individual from feeling like they’re going through this alone (therefore helping to remove any ideas that they’re the only one dealing with issues). Furthermore, therapists can choose to self-disclose instances when they’ve felt a similar way, or they can give their input on how they’d react in a particular situation. This normalizes behavior, as it seems more common and less “other” when you hear a therapist mention that they’ve had similar issues, or would have reacted in a similar way. Finding positives for some symptoms can also help normalize them, such as anxiety having an evolutionary advantage, therefore it’s not just something that’s “gone wrong” with them – just exaggerated.

    Weekly Activity Monitoring:
    I think that the client does seem somewhat motivated to monitor his behaviors for the next week, but he’s definitely engaged during the explanation. He has questions about how much detail he needs to go into, which suggests that he’s not brushing off the activity and is somewhat invested in making sure he does it in a way that’s helpful for him. Mark is paying attention to how Dr. V fills in the form, and is fully participating and responding to questions about what his day typically looks like to fill it in. Furthermore, he asks for clarification on the difference between the accomplishment vs. pleasure numbers, which suggests he’s listening and working through how he’s going to fill in the log in the next week or so. He does state that it seems “daunting”, but he quickly talks through his thought process on what he thinks he’d like to tackle as an eventual result of filling this out. He seems to perk up when discussing the note app to make a note of how his day is going easily, and states that it’s an easier option for him; again, this suggests that he’s at least somewhat motivated as he’s planning out how to potentially go about this. If he had zero motivation or intention for doing the activity monitoring, I don’t feel like he would have asked the questions he had, or have a tentative plan building in his head as Dr. V explains things. He does seem a little more fidget-y than he does in other videos during parts of the conversation. There does seem to be a little bit of hesitation when Dr. V initially brings up that he has to track his days for a couple of weeks, as he sits back in his chair from leaning forward, but he does seem motivated overall.

    I think there are a few behaviors that need to be followed up with in his next session. Mark brings up struggling with the dishes several times during the weekly activity monitoring video, which suggests to me that this is a sticking point he’d like to tackle. He also seems to dislike how late he’s been waking up for work recently, and that he’s sleeping more than he’d like to. These are two specific patterns he brings up himself, so following up with the times and the ratings of these activities seems important (alongside how he feels immediately after them too, e.g., on the days where he feels lower accomplishment for waking up late, does he get less pleasure out of things?). I also think it’s important to follow up on his lack of enjoyment in things, so looking for patterns of behaviors that consistently rank low in pleasure, but are engaged in often, that Mark has previously stated he used to enjoy. It was one of the bigger things he mentions in his initial assessment, especially getting enjoyment from spending time with his dog, so examining the patterns of behaviors around his dog seem important to me also.

    Reply

    • Pawel Zawistowski
      Feb 18, 2021 @ 12:56:19

      Beth,
      I like how you mention that during Mark’s weekly activity log you were interested in his sleeping, doing the dishes, and the time he is spending with his dog as well as how much pleasure he is getting from these activities. By looking into these activities, we would be able to monitor if he has made any improvements in washing dishes which is a chore, he said he was struggling with. And also, we would be able to see if he has been able to sleep better. Ideally if he can improve his sleep his mood can also improve and his overall daily functioning.

      Reply

    • Anne Marie Marie Lemieux
      Feb 19, 2021 @ 14:00:05

      Hi Beth, I always enjoy your posts as you are very articulate. I especially liked your point about using “we” when discussing strategies. It stood out to me in the video as well. It truly shows how collaborative the process is. It appeared to me to inspire hope by implicating that “we” are in this together and have a plan to reach your goal. However, I wonder as the client improves their self efficacy about shifting their own thoughts and behaviors, if and when it switches to you vs. we, or if stays a collaborative we throughout the process while easing the client as the lead. Thanks, for a thought provoking post.

      Reply

  13. Tayler Weathers
    Feb 18, 2021 @ 12:04:22

    With psychoeducation, just like education in schools, the way to adjust for each client is to have a good sense of what your client (like your students) need. Knowing the material is great, but it’s easier to adjust for clients if you have different methods of conveying it: enthusiastic, straightforward, facts-driven, emotion driven, etc. Different clients will prefer different styles. It also depends somewhat on the information – you don’t want to give clients false hope, but instead imbue in them the idea that you know what you’re doing, and that the work of therapy is achievable and worthwhile. This is done by accommodating their needs and responding to their concerns. It’s also done by normalizing: expressing that the problem they’re experiencing, while of course very challenging, is not impossible to overcome. Therapy can help. For some clients, this reassurance will look like statistics or research; for others, it will be your faith in the process that will inspire them and normalize what’s going on. Judy Beck does this with Abe, as well: reassurance that the work of therapy is worth it, and that she believes he can do it. To avoid seeming alienating or lacking empathy, I think the best thing is to sum up what you know about the client (their case formulation) to assure them that you are listening and paying attention, but also to not push them too hard. Don’t say “I know you’ll do all the work and be fixed,” but instead say “Here is what therapy is. Does that sound like something you can do? Does that sound like something you want to do?” Being gentle and empowering the client will make the process much easier – and, as we’ve discussed before, set the expectation that it is client work, not just therapist work, that creates meaningful change.

    As for the behavioral activation video, Mark seemed somewhat hopeful and responsive. His body language seemed engaged, and he actually responded and asked questions. He didn’t seem like the work was too much or overwhelming, but that it was manageable and that he was interested in doing it. This shows some trust in the therapist, but also in the process of therapy. Without that trust, he would be less likely to be responsive, more passive. I think he will do the monitoring, though he does realize it’s a big task. When he realized it didn’t have to be perfect, I think that reassured him a lot – which indicates he does want to try and please, but may not have a lot of faith in himself. For Mark, the thing to target is probably his isolating behavior. Once he starts to be more active, he can start to work on the sleep problems (if he tires himself out he might sleep better) and then the interpersonal problems. Plus, behavioral activation has a decent increase in mood and hope, which will make changing his other problems seem more achievable!

    Reply

    • bibi
      Feb 18, 2021 @ 13:00:17

      Hey tay,
      I loved how you talked about adjusting the conversation to what your client needs. I feel like you want to match the energy your client is giving you to a certain degree. Being wayyy too over enthusiastic with a client that might not be feeling it would set the wrong tone for the rest of therapy. I feel like this is where cultural competency could also play a huge role overall in knowing how your client might respond to certain tones of voices, posture, and energy.

      Reply

    • EB Elizabeth Baker
      Feb 20, 2021 @ 15:33:04

      Hello Tayler!

      You make great points within your post! I especially liked how you included adjusting your way of psychoeducation to fit the client’s preferences on obtaining information (if they like it in a more straightforward manner or enthusiastic manner). I think it would be especially important to ask how well they have retained the information, and what the clinician can do to increase the enjoyment or alertness (being able to stay focused and retain information) when educating clients. I also liked your examples on how to inform clients about therapy while maintaining an empathetic and gentle nature. I am sure clients feel overwhelmed with the information they receive during their first session, but reminding them that this is still a collaborative process, that they will not be working through their distress all by themselves, may make them put a little more trust into the therapeutic process.

      Reply

    • Brianna Walls
      Feb 20, 2021 @ 22:36:17

      Hi Tayler! I like how you said it is important for the therapist to accommodate to their needs and to respond to their concerns. I think it is important to note that not all people react/respond to therapy the same, and therefore, its not one shoe fits all. In addition, it is important to check in with the client and get their feedback about therapy, to make sure that they are benefitting from it and are learning from the therapist.

      Reply

  14. bibi
    Feb 18, 2021 @ 12:58:38

    [Psychoeducation]
    1. Something that I noticed in the first psychoeducation video was how the therapist took an example from the client’s personal life to start explaining the cognitive model. The purpose here was to explain the cognitive model to the patient and how it was connected. By taking an example from the client’s life, it can bring the model into reality for them. It can help better explain things in a salient way for the client instead of hearing more about the technical information of the model. I felt like this was a great option for doing psychoeducation while tailoring it to the client. Additionally, the therapist keeps going back to the client and asking him questions, making sure he understands where it is going and having him help continue the discussion. This is all super important in making this a collaborative process and not just a lecture.
    2. I like how he started with talking about how anxiety is not that bad. The client seems super worried when he says that but as he goes into the psychoeducation about it, he does a good job in explaining why some anxiety is functional. He then goes into how it can vary in severity and frequency and brings her own experiences into the situation. He doesn’t undermine the terror of having a panic attack and she acknowledges that that fear is present, but he does a good job explaining how it is technically something adaptive but isn’t helping in this situation. He also does a good job addressing her fear that she might be dying during a panic attack and explaining how that can’t happen in this situation.

    [Behavioral Activation]
    1. I feel like he does seem interested in filling out the activity monitoring. He starts asking clarifying questions like when he is at work, what should he put. He also explains that he is worried that it could get a bit overwhelming but if he doesn’t have to list minute to minute tasks, then he feels a bit better. Marc also talks about how he wants to change some of his activities/ behaviors, and he thinks that this will help him notice some of these things and places that would help him. Marc seems to understand that this is the starting place for making these changes and he has some important things that he wants to change. He understands that completing this first step is important and seems interested and focused on listening to what the therapist has to say about the activity monitoring.
    2. I think that some important target areas were mentioned in setting up the activity monitoring log. He said that work has been hard for him and that he hasn’t been feeling very good about how is completing his work. I think it would be important to note what he puts down on the log for work to see how he is feeling at work. Additionally, he said that he used to wake up earlier in the morning but lately has been sleeping much later which is hard cause it doesn’t give him much time to get up and get ready for work. I think that this would be important to talk about in a future session and maybe set goals to start waking up earlier to avoid the anxiety associated with feeling rushed in the morning.

    Reply

    • Yen Pham
      Feb 19, 2021 @ 15:23:52

      Hi bibi,
      Thank you for your posting! As we know that Mark mentioned that he has a hard time getting up early and that makes him feel rushed in the morning. We might have predicted that Mark’s haste could make him tired. So in the next session, I think like you too, we should consider to discuss and guide Mark to record his moods and feelings for the day or week and maybe set goals to start waking up earlier. Additionally, I have realized that Mark mentioned he likes to play with his dog, so we should also may guide him to make a self- monitoring on the time he will take his dog for a walk and maybe to go out in dates with his girlfriend.

      Reply

    • Alexa Berry
      Feb 20, 2021 @ 13:35:55

      Hi Bibi,
      I’m glad you got your power back and were able to post because you made a lot of great points! I definitely agree that it can be easier for clients to understand psychoeducation and explanations of the cognitive-behavioral model when it is connected to their own life. I imagine it would be difficult for a client with depression who has been suffering from concentration issues to follow along during psychoeducation if it was all technical terms, and wasn’t closely related enough to their own experience. Something I liked from your section on psychoeducation was how you explained it in terms of this weeks video recordings. I approached this section from a mainly theoretical perspective, but the way you applied it to these cases made the connections very clear. In addition to the behavior patterns you identified for Mark, I also think his social behavioral patterns contribute to his distress as well, and could be worth watching.

      Reply

  15. Carly Moris
    Feb 18, 2021 @ 14:03:16

    1.
    One way to adjust psychoeducation of therapy expectations and the cognitive model to fit a clients needs is to use the clients own experiences when explaining these concepts. When explaining the cognitive model the counselor can use specific events they have discussed with the client, and work with the client to break down these events into thoughts, emotions, and behaviors. This break down can be further tailored to the client, by altering the label of the categories to better fit the client. Like with Lindsey where Dr. V labeled one category physiological symptoms instead of emotions because it was more appropriate for Lindsey’s situation. When breaking down an event into the cognitive model counselors can bring up automatic thoughts and even briefly mention what cognitive distortion the client is experiencing. Breaking down the cognitive model using the clients own experience also offers an opportunity to explain some expectations for therapy. The counselor can point out areas where thoughts and behaviors can be modified and possible interventions they may use in the future. The counselor can also use this as an opportunity to say something like “what if situation x didn’t happen, how would you feel?” From there the counsler can ask what would happen if they had interpreted situation x differently and go on to explain that one of the goals of CBT is to help modify how the client interprets these situations in order to help their presenting problem. By incorporating the clients own experiences into the explanation of the cognitive model and using that to explain possible future areas of intervention you can tailor psychoeducation to the client.
    One of the most important things for normalizing a clients experience in psychoeducation is validating the clients experiences and emotions. When explaining the cognitive model it is important to validate the clients emotions, that even if it is caused by a negative automatic thought the feelings it causes are real and valid. It is important to use good therapeutic skills and demonstrate unconditional positive regard when breaking down a clients experience because it can be uncomfortable for them to break these events apart and see their specific thought, emotions, and behaviors laid out. You don’t want them to feel judged for have a specific thought, emotion, or behavior. When explaining the specific disorder it can be helpful to day that other people also experience this disorder. However, it is important to do it in a way that does not minimize the clients own experience. It can be helpful to explain the symptomology of the disorder and how it can effect an individual or how it relates to the client, like Dr. V did when explaining panic attacks and anxiety to Lindsey. By being able to explain and break down a clients symptoms you can help normalize the experience and instill hope in the client that you can help them. It is important to match this explanation to the client so that they can understand it. You don’t want it to be overly complicated where they cannot understand, or overly simplistic where they feel like they are being talked down to.

    2.
    Mark does seem to be moderately engaged and motivated to attempt monitoring his behaviors over the next week. He seemed to be engaged in the session and like he was actively involved and paying attention to what Dr.V was saying. As well as paying attention to the explanation of the behavioral monitoring log. He was also asking questions about the activity monitoring log, like what he should write down when it came to work. At the end of the session he also seemed happy that he could use a notes app to record the info and fill it in later so that it would be easier to fill out at work. The fact that he cared about what content to include and how to make it more convenient to record the info makes me think that he is motivated to complete the monitoring log. As well as the fact that he said if he could change the withdrawal and how hard he was on himself at work he would feel better, and Dr. V made. It clear that this would help with future interventions for that. Since Mark seems to be motivated to change these behaviors and he knows the motioning log will help, I think he will be motivated to complete the log.
    Based off what I know about Mark I think it would be important to follow up on what he does at work and his withdrawal behaviors. He stated that his two biggest concerns were withdrawal and how hard he was on himself about work. By looking at what he does during a work day we can see if he is being overly hard on himself and how. Pointing out the things that he gets done at work will be a good way to challenge the negative thoughts he has about himself regarding his job. His other concern was withdrawal. This can be examined in two ways either by looking at how many activities he enjoys that he engaged in or times when he did not engage in activities. Looking at the activities he did engage in iOS a good way to increase his positive feeling by pointing out what he did accomplish. When talking about withdrawal one of the things Mark mentioned was spending time with his girlfriend, he also mentioned going for walks with his dog. It may be helpful to specifically review what he did with his girlfriend and/or what he did with his dog. Instead of just focusing on areas where he did not preform activities or withdrew.

    Reply

    • Alexa Berry
      Feb 20, 2021 @ 19:04:19

      Hi Carly,

      I thought you made a very insightful point in your discussion of psychoeducation when you said in addition to explaining things in terms of a clients diagnosis, it can also be useful to break down the cognitive model further to incorporate topics such as automatic beliefs. Your view on psychoeducation highlighted the collaborative nature of CBT, which I also think was evident in the session with Mark. Something else I thought could be a focus or a topic to follow up on for Mark’s next session relates to withdrawal, which you pointed out. Specifically, it appeared to me that social engagement was an issue and a big contributor to Mark using withdrawal as a coping mechanism.

      Reply

    • Anna Lindgren
      Feb 20, 2021 @ 19:54:57

      Hi Carly,

      Great post! I really like how you pointed out that normalizing the client’s condition should be done in a way that doesn’t minimize their distress. Just a slight wording or tone shift can be the difference between them feeling understood and not alone, or them feeling like their therapist is saying that their problems aren’t that bad. As you pointed out, practicing unconditional positive regard is a great way to ensure that you’re portraying empathy and making your client feel understood. Also taking into account to match the language that they use so the explanation is at their level and not condescending or over their head.

      Reply

  16. Zoe DiPinto
    Feb 18, 2021 @ 14:21:18

    1)We may adjust the psychoeducation of what therapy will look like in the presence of more or less distress. When explaining how thoughts, feelings, and behaviors are connected, we may use specific examples from the client’s life to paint a picture of interaction. This may involve setting different standards of expectation for every client. A client with a significant amount of distress will likely have more incremental goals compared to a client with less distress. Similarly, we may stress the importance of a behavior’s effect on thoughts to a client with depression, while focusing on the opposite effect for a client with anxiety. The way in which we present this information and our goal formulation will vary from client to client.
    2) Often, we can “normalize” the experience of having negative thoughts and emotions by saying that nearly everyone experiences them. However, we will want to do so in a way that does not invalidate the individual’s experience. This will require some separation. We should validate the experience and emotions of the client while pointing out maladaptive functions that happen in between. The client should feel validated in their emotional experience and recognize that the maladaptive thoughts are a common experience that is separate from our self that we can have autonomy over.

    1)Yes, he does seem at least moderately engaged and motivated to do the monitoring log. He is leaned forward and saying “yep, yep, okay” to show he understands. He voices some concern about the worksheet looking daunting, but he asks questions to clarify the work. He shows that he is looking towards the future and planning to fill it out.
    2)Based on the information I know about the client, I believe the levels of pleasure and accomplishment are going to be important factors to look at in the follow up session. I’d be interested to see what his behaviors are after doing an activity that he rated high in P or A in comparison to what behaviors he does after doing something with low P or A scores. This may confirm a pattern of withdrawing (that he mentions) after he does a behavior that he does not enjoy. This may target specific behaviors as triggers for negative automatic thoughts that fuel withdrawal.

    Reply

    • Maya Lopez
      Feb 18, 2021 @ 21:52:12

      Zoe,

      I like how you mentioned the explanation will change depending on the client, their diagnosis, and the amount of distress they are in. I also love the fact you mentioned not invalidating the client’s experiences as I also think that may be a hard line to balance on. Of course, we want to normalize the client’s experiences so that they do not think they are far-off “crazy” however we should be sensitive to not seeming like we know their experiences and that everything they feel is normal which would invalidate their suffering. Lastly, you made an important point in helping the client recognize they have autonomy over their behaviors and through therapy can begin to regain some control over how they respond and think about certain situations.

      Reply

    • Christina DeMalia
      Feb 19, 2021 @ 15:43:12

      Hi Zoe,

      I think it’s really important how you pointed out that while the client’s experiences should be normalized, you also want to be sure not to invalidate them. Like many parts of therapy, there can be a fine line to walk, and methods should most often be adjusted to the individual clients. Someone who thinks they are “insane” or “crazy” may benefit from the focus being on how a lot of what they are experiencing is actually normal and just happening in a maladaptive way. Someone who has constantly been told that they are fine or that their problems “aren’t that bad” may benefit more from some normalizing with a larger focus on the fact that the extent to which they are experiencing symptoms is a problem. By validating the difficulties of those clients situations, they may feel more understood and heard. Both normalizing the experiences, as well as being empathetic and validating the clients difficulties are an important part of that process. Adjusting the amount of each to each individual client will help to educate the client while putting them at ease.

      Reply

    • Cailee Norton
      Feb 20, 2021 @ 12:15:37

      Zoe,

      I love that you took the angle of looking at the specific levels of pleasure and accomplishment to guide your follow up. While I focused on specific patterns of behavior, I think you’re right in that this can provide a lot of important information about our client and where we can find rooms for improvement. We all have our interests and gain more pleasure from certain activities than others, and this varies from person to person. By the level of pleasure being consistently low and achievement being consistently low can tell us a lot about the severity of someone’s depression for example, and provides an opportunity to make some changes. Overall I agree that examining these scores can help clinicians to target specific triggers and aid our clients in making adjustments in places they perhaps don’t see problems with (especially in situations of negative coping skills such as oversleeping or withdrawing as Mark tends to do). Good job!

      Reply

  17. Cailee Norton
    Feb 18, 2021 @ 14:35:08

    Psychoeducation
    1. Psychoeducation has the purpose of educating our clients about what the therapeutic process looks like, and preparing them for the skills they will learn throughout the process of therapy. It’s an opportunity for clinicians to outline the importance of understanding the ways we develop behaviors, thoughts and feelings, and our environment. Discussing this interaction, and stressing the importance of the collaborative element that is vital to CBT, we set the clients off at a sound base of which we can build them up from. I think it is critical we establish to our clients that we want them to operate autonomously at some point, while acknowledging that for a while they will need your knowledge and support through the process. Providing this assurance that you will be there to assist them can in many ways relieve some of the distress (definitely not all) they may be feeling about reaching out for help and kind of dealing with the stigmas they may be concerned with therapy. Clinicians use this opportunity to really educate and set the stage for the sessions to come. With Mark and Lindsey you lay out what the sessions will look like in structure, emphasizing the collaborative nature and why that is so necessary for them to stand on their own later. Some clients may come in and be visibly or even vocally distressed to the point in which you may not need to do so much of the psychoeducation part of therapy, and provide some empathy and flexibility in your own clinical expectations of the therapy session to better meet the client where they are. While I don’t think that Mark or Lindsey required this type of approach of being more flexible, it is important for us as clinicians to begin this process but also being attuned to our clients responses to us, “reading the room” if you will. The point of psychoeducation is also to tailor it to their needs. A client may not need to know all about various types of skills in that moment, but providing a generalized example and agenda can allow the client to see what the therapy can look like. This allows for clients to adjust their expectations to the therapy as well. While we are there essentially selling our style of therapy and why it can be beneficial to that particular client, they are also determining if this is the right step for them. By having awareness, setting up an agenda and plan for future sessions, and receiving some feedback from them about how they feel this could work for them allows for the beginnings of a positive and healthy therapeutic alliance.

    2. One of the first things we can do with our clients to normalize their diagnosis is through psychoeducation. By showing them that these skills can be used to aid in their difficulties, as well as showing how often people experience these types of disorders and what has been shown to work towards easing such burdens, we can help show that their cases are not as catastrophic as they initially believed or that they aren’t so isolated in their experience that no one has ever experienced such feelings or distress. Normalizing the occurrence of specific diagnoses can make them feel less of an immovable obstacle, and more of an achievable hurdle. It is important to ensure that we aren’t coming off as cold and almost numb to the experiences of our clients, so validating their experience and showing empathy through various verbal and nonverbal techniques can provide a warmer and more inviting atmosphere for our clients. Providing some encouragement of our belief that our clients can get through these hurdles can also provide some motivation and encouragement to see the therapy through to the end, and feel that they can overcome.

    Behavioral Activation
    1. My first impression of Marks engagement with the behavioral activation is that he is extremely attentive to what you’re saying to him and explaining the process of what a weekly activity log looks like. He’s clearly nodding and identifying with the difficulties of depression and how it’s hard to get things done and not finding pleasure in many things. He’s very open to the suggestions that there are potentially maintaining behaviors that are keeping him struggling. He’s a bit fidgety as well, but I think that’s some discomfort of the initial description of the task at hand, but he is cognitively aware and motivated to force through any kind of anxieties he’s having about it because he’s aware that this can be a great opportunity for introspection in later therapy sessions. His avid agreement in feeling in a rut really signaled to me that he was ready to dive in because he’s over feeling stuck. He admits it can be a bit daunting of a task, really connecting to his body language and fidgetiness, but he’s engaged in what you’re talking about that shows me he is really pushing through. During the process of doing an example day, Mark was participating and answering the questions you asked him to fill it in. He asked his own questions of exactly how to fill in something like work as well as his questions about the achievement and pleasure rating scales, and you were able to elaborate with him without it turning into a bigger ordeal than it needed to be. You were able to bring him back into focus without it becoming a consuming task for him or in the case of the rating scale for it to be an unmotivating situation for having lower numbers.

    2. I would say that one area of focus would be the sleeping in too late for his morning routine. It sounds like he’s got a full day of work ahead of him, and he admittedly said he feels a bit rushed. He mentioned he used to wake up at 6:30 in the morning, but hasn’t been lately. Tracking this wake up time alone can really set the tone for the rest of the day. Within the therapy session reviewing this information, we could mention this sleeping pattern and aim for that to be changed. Then we would do another weekly activity log, and hopefully we would be able to change this rushed feeling in the morning to more calm and preparing for the day ahead. This can really set the tone for the day, and for Mark it might help making him feel more motivated and accomplished by getting up at a more regular time and giving himself enough time to do his regular hygiene routine and get a good breakfast and really start this day. Due to Mark’s depression, this could itself have a great impact on him. Another pattern of behavior that would warrant follow-up review would be his interactions with his girlfriend. He mentioned he felt like he wanted and needed to be more active with her, taking her out on dates, eating together, walking together. These are things that would give him great pleasure, and perhaps being able to recognize the amount he does it already, and how we can work it into his schedule based on his activity log. This allows him to see the option to actually do the things that he wants, and to make changes to allow for those options to flourish. I know that he’s discussed some negative automatic thoughts prior to this clip, but I think engaging in these activities he feels he would gain a lot of pleasure in (as well as accomplishment of doing them instead of other negative coping skills or staying home and isolating himself) especially involving his significant other.

    Reply

    • Yen Pham
      Feb 19, 2021 @ 14:45:38

      Hi Cailee:
      Thanks for your posting, it was very thoughtful and detailed. I agree with you and share your opinion that we must educate the client to normalize their problems. We are therapists, neither denying nor exaggerating clients’ problems. But with the competence, appeal and professionalism of a therapist, we provide clients with the necessary understanding of their problem. I believe that when we build a good relationship, clients will easily trust and work with us as our therapists to create the most effective treatment plan.

      Reply

  18. Lilly Brochu
    Feb 18, 2021 @ 15:06:38

    [Psychoeducation]

    (1) Psychoeducation and the cognitive model are an important part of the therapy process for individuals to gain a deeper understanding of their distress, presenting problems, and how to process and cope with it. Psychoeducation is a key factor that is essential in facilitating the therapeutic process forward and provides the client with the abilities to work collaboratively with the therapist. Moreover, the goal is to provide the client with the tools that will eventually lead them to coping independently without the guidance of a therapist. Lastly, being open and transparent about the CBT process (e.g., collaboration, structure, homework) allows the clients to feel more comfortable, engaged, and motivated to put the work in towards achieving their therapeutic goals and treatment plans.

    Not every client will have the same mental illness or presenting problems, but psychoeducation and the CBT model provides a foundation for each client to jumpstart their therapeutic process that is unique to their situation. For example, Mark and Lindsey, have two completely different diagnoses and presenting problems: depression and panic disorder/agoraphobia. However, they were explained their diagnoses in similar (but different) ways about what triggers their thoughts and feelings as well as why they are feeling the way they do (e.g., negative automatic thoughts, physiological symptoms). If a client needs further clarification, or has difficulty understanding a verbal explanation, moving towards a visual explanation may be more helpful. For example, by using a visual representation of the cognitive model, therapists can apply the client’s personal situation or diagnoses, and create a visual breakdown and a step-by-step explanation about how their thoughts, behaviors, and environment interact and influence each other. Providing the client with information about the CBT model helps them to view themselves, diagnoses, and presenting problems in a different light.

    (2) When clients are presented with information about their specific disorder, they are able to grasp a larger understanding of their diagnoses and their own thoughts, behaviors, and emotions, and what steps can be taken to provide some relief to their distress. Providing psychoeducation on the symptoms they have, the incidence or prevalence rates, and any causal factors in their diagnoses may help to “normalize” their experience and make them feel not so alone in their diagnoses. Going forward, clients tend to feel more hopeful and optimistic that their treatment goals and interventions will be met and help them. However, it is important to not minimize the client’s experience and to overgeneralize the client’s diagnoses or distress. This may come off as lacking empathy or care, and that their situation may be unchangeable.

    [Behavioral Activation]

    (1) Overall, Mark seemed engaged and motivated to attempt to monitor his behaviors over the next week. He seemed interested in the assignment and was open and willing to try it. As Dr. V was explaining the weekly activity monitoring log, both Mark’s verbal and nonverbals were indicators that he was interested in the homework assignment. For example, some verbal indicators were that he asked follow-up questions or any clarifying questions about the homework assignment, which shows that he is focused and committed to understanding and learning. Additionally, he seemed excited that there was a way to modify the homework assignment in a way that works for him (e.g., using an app on his cellphone). As for nonverbal indicators, his eye contact and positioning of his body was directed toward Dr. V and the weekly activity monitoring log, showing that he was fully attending to the material.

    (2) Based on what we know about Mark so far, I would say that important patterns of behavior to assess would be his overall experience doing the homework assignment (e.g., was it easy/difficult, time consuming/quick, positive/negative). It would be important to see how well the homework assignment resonated with Mark. Next, checking in about his daily routines and time management. For example, Mark seemed a bit rushed during his morning routine because he was sleeping in too late, and only had a short amount of time to shower, eat breakfast, and get to work. Other activities that would be important to check in would be activities, such as laundry, washing the dishes, and doing those simple tasks that seem impossible for depressed clients to accomplish. Moreover, asking Mark about his level of achievement and pleasure during the workday would be important to check-in about because it is an environment that is an area of stress for Mark. Lastly, examining Mark’s amount of socialization with his wife and friends as well as his feelings and behaviors of withdrawal and isolation are important patterns of behavior to assess since that was another presenting problem of his.

    Reply

    • Zoe DiPinto
      Feb 19, 2021 @ 12:41:53

      Hi Lilly,
      I appreciate your perspective in ways we can normalize experiences for clients so “they don’t feel so alone.” I can imagine a client feeling patterns of anxiety that are perpetuated by ideas like “No one else feels like this, why am I feeling like this?” or “no one understands me.” or “I should stop feeling this way.” These thoughts are likely making feelings of anxiety stronger. If the clinician can psychoeducate the client in showing that these are common patterns of thinking in many individuals, it may create a sense of community in their suffering and increase feelings of empowerment to confront their problems.

      Reply

    • Connor Belland
      Feb 19, 2021 @ 23:04:14

      Hi Lilly, I agree with you that it is super important to make sure the client fully understand their symptoms and other concepts the counselor is trying to explain to them. I also like how you added that it may be necessary to do a visual representation like drawing the model on the whiteboard if the client does not full understand a verbal explanation.

      Reply

  19. Tim Cody
    Feb 18, 2021 @ 15:48:08

    Psychoeducation:

    (1) How can you adjust psychoeducation of therapy expectations and the cognitive model based on a client’s distress and presenting problems? That is, what can be said (or done) differently?
    What must be assumed is that the client may have little to know understanding of therapy and the cognitive model. It is the therapist’s role to adjust the psychoeducation in order to gear the client’s capabilities and knowledge of both therapy and their presenting problem. What must be stressed to the client is that the therapy is to be a collaboration between the client and the therapist. What I would do differently and spend the majority of my time on this. I would even allow time for the therapist to explain how the therapist’s role should decrease as time goes on and allow for client’s role to increase until the time between the two is complete. Perhaps this is usually avoided during the initial early phases as to not scare the client and build the therapeutic relationship, but clear communication and honesty should be practiced during therapy, both by the therapist and client. I would not put as much emphasis on note taking during the therapy expectations, but rather explain as much as can in a short amount of time about session structure and setting an agenda. During the psychoeducation of the cognitive model, I would spend as much time as I can following through with each of the behaviors, thoughts, emotions that correspond with one another and are affecting the client’s mental health. I would also connect the physiological responses and cues that are associated with the behavior if applicable. If time permits, perhaps have time for the client try to explain the relationship between their thoughts, emotions, and behaviors. This will be done later in therapy, but it may be beneficial for the client to demonstrate their understanding of the cognitive model early on.

    (2) For psychoeducation of specific disorders, what are some ways you can “normalize” each clients’ experience without alienating them or coming off as lacking empathy?
    I would make sure to allow the client to feel heard and not come across that their symptoms are simply listed in the DSM-5 and that is how I know their diagnosis. It may take time, depending on the diagnosis, but it is important for the therapist to be able to communicate clearly the client’s symptoms, how they apply to everyday situations, and allow for proper explanation as to how they can be treated. In the video provided, Dr. Volungis talked his client through understanding her anxiety. When he mentioned right from the start that anxiety is a good thing, she felt very nervous and not at all assured by this fact. She felt that her anxiety was far from normal and at first, he was not paying respect to her anxiety. However, after giving a thorough response, as to how we can utilize anxiety in the right manner and how too much anxiety in other areas can be a hindrance, she felt more relaxed and that he understood where she was coming from. At first glance, he may seemed to be lacking empathy to her specific diagnosis by generalizing or normalizing anxiety, but she grew to accept what he was saying over time and even was reassured to know that her anxiety in the right context was a good thing.

    Behavioral Activation:

    (1) Does this client at least seem moderately engaged and motivated to attempt monitoring his behaviors over the next week? What are the indicators that support your perspective?
    While he might find the task to be tedious, he feels like he is capable of achieving it. He definitely felt more assured when he did not have to keep it to the same format as the one Dr. Volungis provided, and he liked the idea of keeping track on his phone rather than the sheet of paper. More importantly, he felt this could be a beneficial way to track not only the events and tasks he is able to accomplish, but how he felt after the event or task is completed.

    (2) Based on what you know about this client so far (e.g., information from his assessment and this video vignette), what patterns of behavior do you think warrant follow-up in the next session while reviewing his Weekly Activity Monitoring Log?
    The client mentioned that he felt that he was feeling withdrawn based on past events. Often there were times when he cancelled plans with friends or his girlfriend because he was feeling depressed. The activity log will not only allow him to track what events he did or did not do, but it will allow him to plan ahead better and maybe keep more of his plans rather than cancel them. Rating how pleasurable they were and how accomplished he felt will also help him keep track of his emotions. Dr. Volungis mentioned that this is not to make sure his emotions were higher than they were the week before. In fact, some events such as mundane chores can be unpleasant, and that is okay. It is important to be able to monitor these symptoms, what events or tasks he was able to keep, how often he did not get pleasure out of tasks and how accomplished he felt at the end of the week.

    Reply

    • Althea Hermitt- Mcpherson
      Feb 18, 2021 @ 21:45:18

      Hi Tim, I liked that you mentioned that you would follow up on Mark’s task and try to ascertain how pleasurable or accomplished he felt doing certain tasks. You also made mention following up with Mark about events and tasks he was able to follow through with and what emotions he felt when completing these tasks. I mentioned in my post that I also wanted to follow up with Mark about his isolation/ withdrawal behaviors throughout the week, and what precedes his withdrawal. His patterns of behavior throughout the week, for example, physical activity, hygiene routines, sleep pattern, chore completion, taking the dog for a walk, etc. was also something that was interesting to me that I would want to follow up on. I would also want to know if he had any negative automatic thoughts and if so what those were.

      Reply

      • Tim Cody
        Feb 19, 2021 @ 22:08:49

        Hi Althea,
        Thank you for your reply! That is a really good point. Not only would his weekly activity monitoring log aid in his withdrawal periods, but finding out what the preceding events were may help the client and the therapist to understand with the automatic thoughts and withdrawals are coming from. I think Mark could definitely benefit from continuing with his weekly activity monitoring log, for it can assist him with starting his day off better with a well cooked breakfast and assist in tracking his mental health throughout the week.

        Reply

    • Connor Belland
      Feb 19, 2021 @ 22:51:12

      Hi Tim, I really like what you said about making sure the client feels heard and that they fully understand their symptoms and how they may present in daily situations. It is important to try and normalize the clients specific disorder while also showing empathy to their specific situation as a way of validating them more. I also like the idea of reassuring the client saying that anxiety is a good thing because it is a natural way to help us prepare for an upcoming event.

      Reply

  20. Anna Lindgren
    Feb 18, 2021 @ 15:57:21

    Psychoeducation:

    1) When explaining the cognitive behavioral model to clients, counselors can tailor the explanation to a recent example of the client’s own thoughts, behaviors, and emotions. This will put the model into their own specific context and will have more meaning for them. In the example of these videos, Mark’s model featured thoughts, emotions and behaviors because those were pressing concerns for him. Lindsey’s model, on the other hand, replaced emotions with the physiological responses of her panic attacks, as those are more relevant to her presenting problem than emotions.
    2) Educating the client about the prevalence of their disorder or how their symptoms stem from normal human reactions is a great way to normalize the disorder. Counselors shouldn’t come off as too nonchalant or say that it isn’t difficult, because if it wasn’t difficult for the client to manage, they wouldn’t be in therapy. Validating their emotions is always a good way to convey empathy and normalize the experience.

    Behavioral activation:

    1) Mark does seem to be motivated to try monitoring his behavior. He asked thoughtful questions about how to complete the log and when asked about how he would feel if he could change his behavior, he recognized that it would make him feel better.
    2) Based on what I know about the client so far, I would want to follow up on his pattern of withdrawal behaviors as that seems to be causing him the most distress at this point in his treatment.

    Reply

    • Althea Hermitt- Mcpherson
      Feb 18, 2021 @ 21:33:46

      Hi Anna, I liked that you emphasized that clinicians can explain the CBT model to clients by using their recent thoughts, behavior, and emotions in order to seem more meaningful and relatable to the client. I also agree with you that educating the client about their disorder is key in normalizing their experience because at times these individuals tend to feel alone in what they are going through. We all need to remember that whatever we have gone through and overcome is irrelevant to what the individual is going through and it’s not our place to decide that the client’s problems are trivial because their experiences are real to them.

      .

      Reply

    • Maya Lopez
      Feb 18, 2021 @ 21:58:11

      Anna,

      I agree, by using clients’ own examples and experiences, we can tailor psychoeducation to fit them specifically which does give it more meaning and perhaps helps them rationalize the model better than using a random example to which they don’t have emotional ties. I didn’t mention this in my post but I love that you brought up educating the client on the prevalence of the disorder, however, I think this should be used with caution because schizophrenia is less common, it may not be as wise to tell a client with that disorder that they are 1 of the whatever percentage in the country to have it. Lastly, I agree, validating the client’s emotions that may have felt real in a situation and their experiences is helpful to convey empathy and understanding.

      Reply

    • Zoe DiPinto
      Feb 19, 2021 @ 12:56:36

      Anna,
      I agree, I would follow up with Mark about patterns of withdrawal in his activity log. I believe I would be interested in the activities he does before and after his withdrawal behavior. I wonder if the withdrawal is triggered by a behavior that he rated as low P or A. If he completes an activity with more pleasure or accomplishment, will this decrease his likelihood to withdraw after? I would also be interested to see if withdrawing affected his sense of pleasure and accomplishment for the rest of the day. Perhaps targeting to change negative behaviors in the afternoon will decrease his likelihood to withdraw and feel bad for the rest of the day.

      Reply

  21. Connor Belland
    Feb 19, 2021 @ 22:46:33

    1. The use of Psychoeducation and the cognitive model are important parts of therapy when using CBT. Not all clients are the same though so it is important to be able to alter and develop the psychoeducation and use of the cognitive model as you go based on the levels of distress it is causing in the client. With Mark, he seems to have a pretty good understanding of the methods and ideas being introduced to him so it is okay to keep moving forward and get into deeper understanding of the cognitive model. As you explain the different pieces of CBT you can use examples from a real situation your client has been in to better illustrate it for them. This will help them get a better understanding of the concepts and maybe if they react more to a certain idea then that is a sign that maybe this should be investigated more by the therapist. The process can also be adjusted to be more reassuring to the client if it is making them anxious to even talk about distressing events.
    When teaching a client about a specific disorder it is important that you personalize the psychoeducation towards their specific presenting problems so that they better understand. It is important to validate their issues as well and make them feel as they aren’t the only one who suffers from these problems and that its natural for them to feel a certain way based on certain events. Show your understanding of their issues and use empathy and body language can make the client more comfortable and not alienated. Validating a clients specific problems as part as their larger disorder can help to normalize it for the client.
    2. The client does seem somewhat engaged and motivated to attempt monitoring his behavior as he seems excited by it in his voice and is hopeful that it will help him. He says he thinks planning out his activities could help him stick to his plans more. Although he seems doubtful at some points that he will be able to stick to doing it all the time, he is engaged. He starts to already think about what his schedule is going to look like in the upcoming weeks and tries to plan out some things he would like to incorporate into his schedule that he think would help him feel better. He also thinks about changes he could make and thinks that writing them in his monitoring log could help him make those changes.
    I think it is important for Mark to follow up on the activities that give him pleasure like taking some time for himself. He says he wants to spend more time doing activities outside of the house with his girlfriend and his dog. He should do some things to change up his routine as well like maybe waking up a little earlier in the morning so that he isn’t in a rush to go to work. He also definitely wants to avoid withdrawing from the world whenever he is feeling emotionally distressed and try to face his problems more.

    Reply

    • Cailee Norton
      Feb 20, 2021 @ 12:11:01

      Connor,

      I’m glad you mention that the uniqueness of every client. While we understand various techniques and mechanisms to bring about change for a wide range of clients, it is vital to keep their unique experience in mind. We often need to be flexible in our approach and assessment of both a client as well as their situation or circumstances. Just this fact alone keeps clinicians on their toes, and while it can be easier to attempt to fit into a fixed schedule and “lesson plan” for any client we receive, it would ultimately do a disservice to both the clients as well as ourselves. Adapting to each circumstance and using our knowledge to best educate our clients on what is important to them is how we can progress forward through therapy. Great insight into Marks situation as well, I agree as well about the sleeping habits of Mark being of interest for behavioral activation, as well as participating in more activities he finds enjoyment. Sometimes there’s really nothing better than getting outside and getting fresh air to clear your mind and relax from the week.

      Reply

  22. Nicole Giannetto
    Feb 20, 2021 @ 13:06:03

    Psychoeducation
    1)
    The psychoeducation of therapy expectations and the cognitive model can be adjusted based on the client’s distress and presenting problems by coming at it through an angle that is understandable, yet informative, and relates to the client’s current problems. It is always important to emphasize that CBT is collaborative in nature, and that you, as the therapist, will engage in continual back and forth dialogue with the client throughout therapy. Another important aspect of CBT is to educate the client on how the process will consist of working together through utilizing evidence such as client progress We are going to work together and utilize evidence we have, such as utilizing tracking progress. For anxious clients, it can be helpful to emphasize to them that the cognitive behavioral process can be adaptive as it goes, but will follow a mainly structured session format. This can mae the client feel more comfortable in the fact that they will experience change, but the format of therapy will remain stable over time. In the video, you can see that Mark becomes even more fidgety with his hands as Dr. V explains that most times before change occurs, we can experience more distress. This simply means that we are uncovering aspects that relate to the problems that we face, but it is good to allow these to come up, because it shows the client is bringing awareness to the issue and can move forward to actively begin monitoring and eventually change the behaviors.

    2)
    I think an important way as a therapist that I can normalize my clients’ experience without coming across as lacking empathy as I educate them on specific disorders is to come from a place from the heart rather than from a book (DSM-V). As a therapist, I will have the knowledge on specific disorders, and I will educate my client on those, but it is key to remain human in these instances, because I may not know how much the client understands their problem. Learning about a disorder, such as depression, can cause a client to become even more depressed as well as anxious. To ease their symptoms, it would be good to acknowledge that people across the world experience things like depression, and it is HARD (distressing/unmanageable). I want to explain to them that I begin our therapeutic process by providing them education on what depression (or their specific disorder/problem) is/looks like, how it affects people differently, and to identify how it is affecting the client specifically. I think that by explaining how it can affect people differently may help the client feel somewhat relieved that they are not alone, and that perhaps they have come across folks that suffer from depression and may deal with it differently. It isn’t always clear to tell if someone suffers from depression based on the surface, a lot of people tend to hide it. I also may mention that once we begin to work on identifying areas of the problem, it can cause more distress. This increase in distress often comes before the positive results are seen and felt. I will assure them that this is a common part of the process and that I will be here throughout it to offer support and guidance where they may need. Lastly, I will continually check in with my clients during psychoeducation to make sure they understand what I am saying, and to ask for any clarifications they may have.

    Behavioral Activation
    1)
    Mark does fidget with his hands throughout the session. This may indicate that he is experiencing feelings of anxiety, but it could also be evidence that he is excited to begin this next phase of therapy. You can also tell he is understanding what he is experiencing and what he should work on based on the summary and feedback that Dr. V is giving him prior to explaining the weekly activity monitoring log. As Dr. V breaks down the process of completing the weekly activity monitoring log, Mark changes his seating position to sit more forward which shows he is engaged. He also asks questions to clarify how he should approach the monitoring log, which shows he is both engaged and appears to be motivated, although he does seem anxious or apprehensive about completing certain tasks. Mark is pretty aware of what problems he is experiencing, and what activities he should work to engage in, but because he is depressed it may be hard for him to start these activities once he is out of session and in charge guiding his daily activities.

    2) Based on what you know about this client so far (e.g., information from his assessment and this video vignette), what patterns of behavior do you think warrant follow-up in the next session while reviewing his Weekly Activity Monitoring Log?
    For Mark, some behaviors that I would want to follow-up with in the next session regarding his weekly activity monitoring log would be on his ability to follow through on activities, especially surrounding socialization with his friends and engaging in fun, day-time activities with his girlfriend and dog. He has identified that he enjoys walking his dog, and would like to get him to the park. One suggestion was to bring his girlfriend along which would offer an opportunity to get outside and enjoy an activity that he likes with her. Another thing to follow-up on is how Mark is rating his activities. He did mention he didn’t rate certain activities such as tasks at work. This was because he was either busy, or the experience wasn’t pleasant so he may have avoided reflecting on it. Lastly, a big item to follow-up on is how Mark is doing with starting his days. He struggles with waking up at a decent time to give himself enough time to get ready for his day. Mark was educated on how waking up at a decent time can help him feel prepared and be more motivated to begin his day.

    Reply

    • Brianna Walls
      Feb 20, 2021 @ 22:19:01

      Hi Nicole! I liked how you noticed her was fidgeting with his hands during the beginning of the session. I noticed this too but wasn’t sure if it was something to note; I’m glad you did!
      I agree with you, I think it is important that the therapist and Mark should follow up with an activity such as bringing his dog to the park. He talks about this a lot and it seems like it is very important to him and he enjoys it a lot.

      Reply

  23. Anna Lindgren
    Feb 20, 2021 @ 17:22:49

    Hi Nicole,

    Great observation about Mark’s apparent apprehension at the thought of experiencing short-term heightened distress as a normal aspect of treatment progression. This is an aspect of therapy that I think is important to set expectations for so that a client doesn’t see their increased distress as a sign that therapy isn’t working and quit or find a new therapist. I also agree with how you made a point to say you would check in with clients during the psychoeducation process to make sure they understand and don’t feel like they’re being talked down to.

    Reply

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Adam M. Volungis, PhD, LMHC

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