Strategy – The Heart of Cognitive Behavioral Therapy

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.

Maintaining Gains in CBT

One of my favorite things about cognitive behavioral therapy (CBT) is how quickly it makes a difference in the lives of clients who receive it.

In my clinical practice, I often see that something “clicks” in my clients after 4-8 sessions of CBT. That is, after 4-8 sessions, many clients who diligently practice their CBT tools in between sessions report that they feel better, that their problems seem less overwhelming, and that they have hope that their can achieve fulfillment and life satisfaction. The research literature has confirmed this phenomenon, with scholars referring to these improvements as “sudden gains.”

The notion of “sudden gains” is not new. Over a decade ago, Tang and DeRubeis (1999) found that over 50% of clients who ultimately respond to CBT experience a sudden gain, and impressively, that sudden gains were maintained across the rest of treatment and persisted 18 months following treatment in most cases.

What can therapist and clients do to put themselves in the best position to have a sudden gain?

Therapists can make sure that clients thoroughly understand the theory that underlies CBT and can articulate the manner in which it applies to their lives.

Therapists and clients can practice the CBT tools in session to ensure that clients understand exactly how to use them and to increase clients’ confidence that they’ll be able to apply them in their lives outside of session.

Clients can fully commit to completing the between-session work in order to gain practice with the CBT tools.

If it initially appears that the CBT tools are not helpful, then therapist and clients can work together to creatively modify them on the basis of clients’ preferences, strengths, and challenges while still retaining their “spirit.”

I’ve also seen some instances when clients experience a sudden gain after using one or two specific CBT tools, then choose to focus on something else in subsequent sessions, and then forget to apply the tools the next time the encounter a stressor in their lives. This is not unexpected — in many instances, unhelpful cognitive and behavioral patterns that characterize clients when they first present for treatment are entrenched. Even if it seems that they are modified after only a few sessions of CBT, it is important to realize that CBT tools are life skills that must be incorporated into one’s typical way of viewing the world and behaving, not just be practiced in a few sessions and then forgotten about.

Thus, to ensure that clients’ sudden gains are maintained over time, therapists and clients can do the following:

Clients can continue to practice CBT tools in between sessions, even if the focus of therapy has moved in another direction, in order to ensure that the tools are activated just as easily as unhelpful patterns of thinking and behavior.

Therapists and clients can focus on relapse prevention in session, such that they anticipate future stressors that might trigger unhelpful thinking and behavior and “cope ahead” to articulate the precise manner in which CBT tools will be applied to handle them.

Clients can create easy-access reminders of the CBT work done in session (e.g., a description of a CBT tool on an index card) and consult the reminders immediately in times of vulnerability.

I often use the metaphor of a “groove in the brain” with my clients. If a client who struggles with depression has been thinking and behaving in an unhelpful manner for several years, it makes sense that her “depression groove” would be quite deep. CBT helps clients to carve out a new “groove in the brain.” However, time and practice are needed to ensure that the new groove is as deep as the original groove, and often, this practice occurs even after the course of CBT has ended.

My advice to people who have tried CBT but have found it unhelpful? Keep an open mind, and fully commit to practicing CBT tools for several weeks before drawing the conclusion that they are unhelpful. It may just be that the new groove has been dug out fully. With time and patience, you will see that you will acquire new cognitive and behavioral patterns, and it is very possible that all of the work you put in will suddenly come together in the form of a sudden gain.

Tang, T. Z., & DeRubeis, R. J. (1999). Sudden gains and critical sessions in cognitive behavioral therapy for depression. Journal of Consulting and Clinical Psychology, 67, 894-904. doi: 10.1037/0022-006X.73.1.168

Success Logs

In the midst of depression, anxiety, and life stress, it’s easy to focus on what’s going wrong and ignore what’s going right.

A central premise of the theory that underlies cognitive behavioral therapy (CBT) is that negative or unhelpful thinking contributes to negative mood states. Thus, a common tool used by cognitive behavioral therapists is to help clients acquire the skill to evaluate the evidence that supports a negative or unhelpful thought and the evidence that does not support a negative or unhelpful thought.

Sound easy? In my experience, many clients encounter great difficulty in identifying or recalling evidence that does not support their negative or unhelpful thought.

To overcome this obstacle, my clients often keep a “Success Log.” A Success Log allows clients to keep track, in real time, of evidence that does not support a negative or unhelpful thought. It is called a Success Log because, in many instances, what clients record are instances in which things do go right for them, or instances in which they were successful in achieving a desired outcome. Over time, they accumulate more and more instances that support a more helpful way of viewing their life circumstances.

A Success Log can be adapted for whatever issue with which a client is currently struggling. Does he experience anger because he believes nothing goes his way on his commute to work? Have him record all of the instances in which he hits a green light, rather than a red light. Does she experience anxiety because she believes she will have a panic attack during a flight? Have her record all of the instances in which she flies and does not have a panic attack. Does he generally believe that he is incapable of dealing with daily life? Have him record all of the instances in which he solved a problem that he encountered in daily living.

When they are maintained diligently, Success Logs document convincing evidence that the world is not so black or white — and that life is not as bleak or dangerous as once one thought. And once the evidence is recorded on the Success Log, it cannot be erased or ignored. How gratifying it is to see items rapidly accumulate on clients’ Success Logs. I have seen many instances where the active use of the Success Log seems to have facilitated a turning point in the course of treatment.

I tell my clients, now that they have identified successes, they aren’t allowed to forget them! The Success Log is one way to ensure that this happens.

Welcome to my blog!

As you can see from my web site, I have a number of areas of professional interest ranging from understanding and treating adjustment difficulties associated with childbirth, to developing innovative ways to decrease suicide risk, to translating research from the fields of social psychology and communication studies in order to help couples maintain and enhance their relationships.

This means that I read a lot! I’m continually working on projects in one or more of these areas, which requires me to keep up to date on the research literature, relevant treatment approaches, and attention given to these topics in the media.

When I read about these and other professional topics, I often have ideas about ways to translate what is being said to my clients, or ways that I can inform other clinicians about what is being said so that it can, in turn, inform their work with their own clients. There have been countless times in which I have described to clients results from what, on the surface, seems to be a dry research study, as a way to design a creative cognitive behavioral intervention that addresses a specific problem with which they are struggling. Oftentimes, these creative interventions are among the most meaningful strategies or pearls of wisdom that clients take away from our time together.

I view this blog as a way for me to share the knowledge that I am acquiring that pertain to my specialty areas as well as other topics in psychology and psychotherapy. I hope to communicate ways this information, particularly information that is hidden in academic journals and books, is relevant to the daily lives of clients who struggle with emotional, behavioral, and/or adjustment problems. I also hope to share my perception of the manner in which other clinicians might find this information helpful in their own practice.

This blog is not a substitute for mental health treatment. Nor is it a substitute for systematic training in evidence-based treatments. What it is meant to do is to stimulate critical thinking in consumers and mental health professionals alike, so that those who practice or participate in psychotherapy can approach it with knowledge of relevant scientific evidence and a bit of creativity.