01 - 22. Problems in Therapy
22. Problems in Therapy
P roblems of one kind or another arise with many clients. Even experienced therapists encounter difficulties at times when establishing the therapeutic relationship, conceptualizing a client’s difficulties, or consistently working toward joint objectives. You shouldn’t be able to help every client (or help every client enough). I certainly haven’t helped every client over the course of my career. It’s not reasonable to expect yourself to avoid problems. It is reasonable to develop your skills in uncovering problems, specifying them, conceptualizing how they arose, and developing a plan to remediate them. It’s useful to view problems or stuck points in therapy as opportunities for you to refine your conceptualization of the client. In addition, problems in therapy often provide insight into problems the client experiences outside the office. Finally, difficulties with one client provide an opportunity for you to refine your own skills, to promote your flexibility and creativity, and to gain new understandings and expertise in helping other clients, as problems can arise related to both clients’ characteristics and therapists’ relative weaknesses. This chapter describes how to identify difficulties in treatment and how to conceptualize and remediate these problems. You will find the answers to these questions in this chapter: How do you know if there’s a problem in treatment? How can you conceptualize problems? What kind of problems can arise? What can you do at stuck points? How can you remediate problems? PROBLEMS IN THERAPY
UNCOVERING THE EXISTENCE OF A PROBLEM You can uncover a problem in a several ways: • By listening to clients’ unsolicited feedback and by directly eliciting their feedback, during and at the end of the session. • By periodically asking clients to summarize what you’ve just discussed in session and checking on their depth of understanding and agreement. • By tracking improvement according to objective tests and the client’s subjective reports, and measuring progress toward goals. • By reviewing recordings of therapy sessions alone or with a colleague or supervisor and rating the tape on the Cognitive Therapy Rating Scale (beckinstitute.org/CBTresources). Elicit clients’ permission to record therapy sessions to review with a peer or an experienced and competent CBT therapist or supervisor. Obtaining clients’ consent is usually not a problem if you present it in a positive light: “I have an unusual opportunity for you that I can only offer a few clients [or ‘that I’m only offering to you’]. I want you to feel free to say yes or no. I occasionally record therapy sessions so [my supervisor] and I can listen to them and figure out how I might be able to be more helpful. If we record our sessions, you’ll get the benefit of [his or her] input. I’ll keep your name confidential, and we’ll delete the recording immediately after listening to it. (pause) Is it okay with you if we start taping the session now? If it bothers you after a few minutes, we can always turn it off or delete the recording at the end of the session.” CONCEPTUALIZING PROBLEMS Having recognized that a problem exists, try to understand your clients’ internal reality. How do they view themselves, others, and their world? How do they process their experiences? What obstacles might inhibit their ability to take a more functional perspective of their difficulties? Be alert for automatic thoughts blaming clients (e.g., “They’re Cognitive Behavior Therapy: Basics and Beyond
resistant/manipulative/unmotivated”). These labels tend to alleviate a therapist’s sense of responsibility for resolving the difficulty and to interfere with problem solving. Instead, ask yourself: “What has the client said (or not said) or done (or not done) in session (or between sessions) that’s a problem?” You might ask the same question about yourself, to rule out a mistake you may have made. Next, you would ideally consult with a supervisor who has reviewed a recording of the entire therapy session. You will undoubtedly need help in determining whether the problem is related to the client’s dysfunctional cognitions and behaviors, errors you have made, treatment factors (such as the level of care, format of therapy, or session frequency), and/or factors external to treatment (e.g., an organic disease, a psychologically toxic home or work environment, ineffective medication or deleterious side effects, or an absence of needed adjunctive treatments; J. S. Beck, 2005). Having identified a problem that calls for a change in what you’re doing, conceptualize the level at which the problem occurred: • Is it merely a technical problem? For example, did you use an inappropriate technique or use a technique incorrectly? • Is it a more complex problem with the session as a whole? For example, did you correctly identify a key dysfunctional cognition but then fail to intervene effectively? • Is there an ongoing problem across several sessions? For example, has there been a breakdown in collaboration? TYPES OF PROBLEMS Typically, problems occur in one or more of the following categories:
- Diagnosis, conceptualization, and treatment planning
- The therapeutic relationship
- Motivation
- Structure and pace of the session
Problems in Therapy
The Therapeutic Relationship Collaboration “Have the client and I truly been collaborating? Are we functioning as a team? Are we both working hard? Do we both feel responsible for progress?” “Have we been working on what’s most important to him?” “Have we agreed on the goals for treatment?” “Have I elicited agreement with and provided the rationale for interventions and Action Plans?” “Have I guided her to an appropriate level of adherence and control in the therapy session?” Feedback “Have I regularly encouraged the client to provide honest feedback?” “Have I monitored his affect during the session and elicited automatic thoughts when I noticed a shift?” “Have I responded effectively to her negative feedback?” Client’s View of Therapy and Therapist “Does the client have a positive view of therapy and of me?” “Does he believe, at least to some degree, that therapy can help?” “Does he see me as competent, collaborative, and caring?” Therapist’s Reactions “Do I care about this client? Does my caring come across?” “Do I feel competent to help her? Does my sense of competence come across?” “Do I have negative cognitions about her or about myself with respect to this client? Have I evaluated and responded to these cognitions?” “Do I see problems in the therapeutic alliance as an opportunity for enhancing progress versus assigning blame?” “Do I project a realistically upbeat and optimistic view of how therapy can help?” Motivation “How motivated does the client seem?” “What have I done to motivate him? Do we regularly link his goals and actions to his aspirations and values?”
Problems in Therapy
“Does he see advantages for not getting better?” [When relevant] “Have I addressed his sense of helplessness or hopelessness?” Structuring and Pacing the Therapy Session Agenda “Do we quickly set a complete and specific agenda toward the beginning of the session?” “Do we prioritize agenda topics and decide how to split our time?” “Do we collaboratively decide which topic to discuss first?” “Do we collaboratively make sound decisions about deviating from the agenda?” Pacing “Do we allot and spend an appropriate amount of time for the standard session elements: mood check, setting the agenda, update and Action Plan review, discussion of agenda topic(s), setting new Action Plans, periodic summaries, and feedback?” “Do we collaboratively decide what to do if more time is needed for a problem than we have allotted?” “Do I appropriately and gently interrupt the client when needed? Do we spend too much time on unproductive discourse?” “Do I ensure that she will remember the most important points of the session and is highly likely to complete the new Action Plan? Does she feel emotionally stable before I end the session?” Socializing the Client to Treatment Goal Setting “Has the client set reasonable, concrete goals based on his/her values and aspirations? Does the client keep these goals in mind throughout the week? Is he committed to working toward thevse goals? Are these goals under his control, or is he trying to change someone else?” “Do we periodically review progress toward his goals?” “Do I help him firmly keep in mind why it’s worth it to work in therapy (i.e., to achieve his aspirations and live life according to his values)?” Cognitive Behavior Therapy: Basics and Beyond
Expectations “What are the client’s expectations for herself and for me?” “Does the client believe all her problems can be solved quickly and easily? Or that I alone should solve her problems? Does she understand the importance of taking an active, collaborative role?” “Does she understand the necessity of learning skills and using them regularly between sessions?” Problem Solving/Goal‑Focused Orientation “Does the client specify issues to work on or goals to work toward?” “Does he collaborate with me to solve problems instead of just airing them?” “Does he fear solving current problems because then he will have to tackle other problems (such as a decision about a relationship or work)?” Cognitive Model “Does the client understand that • automatic thoughts influence emotion and behavior (and sometimes physiology)? • some automatic thoughts are distorted and/or unhelpful? • she can feel better and behave in a more adaptive way when she evaluates and responds to her thinking?” Action Plan “Have we designed Action Plans around the client’s key issues, goals, and values?” “Does he understand how the Action Plan relates to the work of the therapy session and to his overall values and goals?” “Does he think about our therapy work throughout the week and complete Action Plans thoroughly?” Responding to Dysfunctional Cognitions Identifying and Selecting Key Automatic Thoughts “Do we identify the actual words and/or images that go through the client’s mind when she is distressed?” “Do we identify the range of her relevant automatic thoughts?” “Do we select key thoughts to evaluate (i.e., the thoughts associated with the most distress or dysfunction)?”
Problems in Therapy
Responding to Automatic Thoughts and Beliefs “Do we identify the client’s key cognitions and also evaluate and respond to them?” “Do I avoid assuming a priori that his cognitions are distorted? Do I use guided discovery and avoid persuasion and challenge?” “If one line of questioning is ineffective, do I try other ways?” “Are some of his automatic thoughts part of a dysfunctional thought process? If so, have I taught him to disengage from the thought and focus on valued action?” “Having collaboratively formulated an alternative response, do I check to see how much he believes it? Does his distress decrease?” “If needed, do we try other techniques to reduce his distress? Do we mark relevant cognitions for future work?” Maximizing Cognitive Change “Do we record the client’s new, more functional understandings for her to read as part of her Action Plans?” Accomplishing Therapeutic Goals in and across Sessions Identifying Overall and Session‑by‑Session Objectives “Have I appropriately expressed to the client that the objective of treatment is not only to get better but also to learn skills to stay better?” “Do I help him identify one or more important issues or goals to discuss in each session?” “Do we devote time to both problem solving and cognitive restructuring?” “Do Action Plans incorporate both behavioral and cognitive change?” Maintaining a Consistent Focus “Do I use guided discovery to help the client identify relevant positive and negative beliefs?” “Can I state which of her beliefs are most central and which are narrower or more peripheral?” [Toward the middle of treatment] “Do I consistently explore the relationship of new obstacles to her central beliefs? Are we doing consistent, sustained work on her central beliefs [both positive and negative] at each session instead of only crisis intervention?” “If we have discussed childhood events, was there a clear rationale Cognitive Behavior Therapy: Basics and Beyond
for why we needed to do so? Have I helped her see how her early beliefs relate to current difficulties and how such insight can help in the coming week? Or how early experiences support her positive beliefs?” Interventions “Do I choose interventions based on both my goals for the session and the client’s agenda?” “Do I check how distressed he felt and/or how strongly he endorsed an automatic thought or belief both before and after an intervention so I could judge how successful the intervention was?” “If an intervention is relatively unsuccessful, do I switch gears and try another approach?” Processing Session Content Monitoring Clients’ Understanding “Have I summarized [or asked the client to summarize] frequently during the session?” “Have I asked her to state her conclusions in her own words?” “Have I been alert for nonverbal signs of confusion or disagreement?” Conceptualizing Problems in Understanding “Have I checked out my hypotheses with the client?” “If he has difficulty understanding what I am trying to express, is it due to a mistake I have made? To my lack of concreteness? To my vocabulary or level of abstraction? To the amount of material I’m presenting in one chunk or in one session?” “Is a difficulty in understanding due to his level of emotional distress in the therapy session? To distraction? To automatic thoughts he is having at the moment?” Maximizing Consolidation of Learning “What have I done to ensure that the client will remember key parts of the therapy session during the week and even after therapy has ended?” “Have I motivated her to read therapy notes daily?”
Problems in Therapy
STUCK POINTS At times, clients may feel better during individual sessions but fail to make progress over the course of several sessions. If you’re an experienced CBT therapist, you may not need to ask yourself the preceding questions. Instead, first make sure that you have a correct diagnosis, conceptualization, and treatment plan tailored for the client’s disorder (and have correctly employed techniques). Then you can assess the following, alone or with a supervisor: “Do the client and I have a solid therapeutic alliance?” “Do we both have a clear idea of his values and goals for therapy? Is he committed to working to achieve these goals?” “Does the client truly believe the cognitive model [that her thinking influences her mood and behavior, that her thoughts may be inaccurate or unhelpful, and that responding to her dysfunctional cognitions positively affects her emotions and behavior]?” “Is the client socialized to CBT—does he contribute to the agenda, collaboratively work toward resolving problems and obstacles, do Action Plans, and provide feedback?” “Is the client’s biology [e.g., illness, medical condition, medication side effects, or inadequate level of medication] or her external environment [e.g., an abusive partner, an extremely demanding job, or an intolerable level of poverty or crime in her environment] interfering with our work together?” REMEDIATING PROBLEMS IN THERAPY Depending on the identified problem, you might consider the advisability of one or more of the following: 1. Doing a more in-depth diagnostic evaluation 2. Referring the client for a medical or neuropsychological examination 3. Refining your conceptualization and checking it out with the client 4. Reading more about the treatment of the client’s disorder(s) 5. Seeking specific feedback from the client about his experience of therapy and of you Cognitive Behavior Therapy: Basics and Beyond
- Reestablishing the client’s aspirations, values, and goals for therapy (and possibly examining the advantages and disadvantages of working toward them) 7. Reviewing the cognitive model with the client (and eliciting doubts or misunderstandings) 8. Reviewing the treatment plan with the client (and eliciting concerns or doubts) 9. Assessing the client’s expectations for how she’s going to get better (What does she think you need to do? What does she think she needs to do?)
- Emphasizing setting and reviewing Action Plans in session and accomplishing Action Plans throughout the week
- Working consistently on key automatic thoughts, beliefs, and behaviors across sessions
- Checking on the client’s understanding of session content and recording the most important points
- Based on the client’s needs and preferences, changing (in one direction or the other) the pace or structure of the session, the amount or difficulty of material covered, the degree of empathy you’ve been expressing, the degree to which you have been didactic or persuasive, and/or the relative focus on resolving obstacles In addition, you should monitor your own thoughts and mood when seeking to conceptualize and remediate difficulties in therapy because your cognitions may at times interfere with problem solving. It’s likely that all therapists, at least occasionally, have negative thoughts about clients, the therapy, and/or themselves as therapists. Typical therapist assumptions that interfere with making changes include: “If I interrupt the client, he’ll think I’m controlling him.” “If I structure the session with an agenda, I’ll miss something important.” “If I record a session, I’ll be too self-conscious.” “If my client gets annoyed with me, she’ll drop out of therapy.” You may benefit from a model of personal practice in which you reflectively focus on your development, both personal and professional, on
Problems in Therapy
an ongoing basis. A workbook can facilitate this work (Bennett-Levy et al., 2015). Finally, when you encounter a problem in treatment, you have a choice. You can catastrophize about the problem and/or blame yourself or the client. Alternatively, you can turn the problem into an opportunity to refine your skills of conceptualization, treatment planning, and establishing a sound therapeutic relationship. Difficulties often provide opportunities to improve your technical expertise and your ability to vary therapy for the specific needs of each client. SUMMARY You are bound to face challenges in treatment. It’s important not to blame yourself or the client. Some difficulties arise because you’re human and, therefore, fallible. Other difficulties arise because your client is human and, therefore, fallible. You may very well learn the most from clients who have been challenging to treat. At every session, it’s important to monitor clients’ emotional experience, cognitions about therapy and about you, their depth of understanding, and their progress so you can uncover problems. When you do identify a problem, conceptualize it. Is there something the client is doing or not doing or saying or not saying in session or between sessions that’s a problem? Is there a problem with something you’re doing or not doing or saying or not saying that’s a problem? Is it a limited problem or a more general one? Use the questions in this chapter to diagnose what’s going on and create a plan to improve treatment. REFLECTION QUES TIONS Which kinds of problems do you think you’ll have most difficulty handling? Why? What can you do? PRACTICE EXERCISE Imagine that you have a client who has failed to make progress for the past four sessions. Write a plan for how you can improve the situation. Cognitive Behavior Therapy: Basics and Beyond
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