Clients who commit to psychotherapy invest a great deal of time, energy, and resources. As a psychologist who regularly sees clients in psychotherapy, it is important for me to respect that investment. It is important for me that we make good use of our time, that my clients’ money is well-spent. My motto is that I like to do my part to ensure that each of my clients leaves each session with something more than he or she came with, whether that something more is a tool or skill, a solution to a problem, a new way of looking at life’s challenges, or some other corrective learning experience.
In order to achieve that lofty goal, I believe that that it is essential for therapists to think strategically in their work with clients. Thinking strategically means that therapists set up discussion in session in a way that allows them to deliver some sort of intervention that is expected to make a difference in their clients’ lives. Thinking strategically means that the therapist has conceptualized a defined pathway by which the work done in session will affect their clients’ clinical presentations. Although my strategic approach to therapy has its roots in cognitive behavioral theory and therapy, I believe that thinking strategically is important for therapists of any theoretical orientation. In my book, Strategic Decision Making in Cognitive Behavioral Therapy, I outline four central characteristics of strategic therapeutic interventions that are delivered during the course of cognitive behavioral therapy (CBT).
First, the intervention should follow logically from the cognitive case conceptualization. The cognitive case conceptualization is the application of cognitive behavioral theory to any one client. It provides a template to understand the genetic, psychological, and environmental factors that are hypothesized to explain the etiological, maintaining, and exacerbating factors associated with a client’s emotional distress. When a therapist has a rich conceptualization of a client’s clinical presentation, he or she will have a sense of the most central modifiable factors that can be targeted in treatment. A good conceptualization allows the therapist to hone in on key issues and processes, rather than those that are tangential or peripheral.
Second, the therapeutic intervention should be decided on collaboratively by the therapist and client, and the therapist should seek regular feedback in order to ensure that the client understands the rationale for the intervention and buys into it. Collaboration is a fundamental tenet of CBT. All things being equal, if more than one therapeutic intervention is indicated by the cognitive case conceptualization, then the therapist relies on the client’s expertise on his or her own situation, strengths, and preferences to decide which one to pursue.
Third, the therapeutic intervention should set up the client to leave the session with something more than he or she had at the beginning of the session. Here is where my motto is put into action. Cognitive behavioral therapists want their clients to notice some benefit in the short-term as well as the long-term without having wait months and months to see a difference.They aim for each session to move treatment forward in some way, such that there is a thread that runs across sessions and that each session contributes momentum to a positive outcome.
Fourth, the therapist should commit fully to the therapeutic intervention, refraining from second-guessing him- or herself and ensuring the the intervention is seen through in its entirety. Too often, therapists get “cold feet” when their clients do not respond in the expected manner, and they abandon the intervention before truly delivering the full dosage. This creates a self-fulfilling prophecy, in that it a therapist delivers an intervention only part-way, then the likelihood that the intervention is unsuccessful increases significantly.
One of my trainees jokingly said to me, “Boy, you can’t coast when you do CBT.” I agree with this sentiment — it requires much “brain power” to think strategically while simultaneously being 100% there with your client and maintaining a strong therapeutic relationship. However, the payoff can be tremendous.
For those who you who are reading this who are in therapy — ask yourself if you can recognize a strategy that your therapist is using. If the answer is no, you and your therapist might have fallen into a pattern in which you are discussing many details of your life and providing updates, but not applying strategy in order to make tangible changes. Reviewing your treatment plan with your therapist should help the two of you refocus and hone in on specific treatment targets. For those of you who are reading this who are contemplating seeing a therapist — when you have your first visit, be sure to ask your therapist about his or her theoretical orientation and the specific manner he or she expects his or her interventions to make a difference in your particular clinical presentation. And for those of you who are reading this who are therapists — think back to the sessions you felt best about, and ask yourselves what happened in those sessions. My bet is that you responded in a strategic manner to an issue introduced by your client, and that strategy led you to arrive upon a tangible resolution, conclusion, or plan of action by the end of the session.
Stay tuned for more blog posts on the strategic delivery of CBT.