Chapter 12: Challenges in Conducting CBT Flashcards
Challenges that originate with the client (6)
- lack of adherence to treatment
- clients who are overly eager to please
- clients who are demanding, aggressive or angry
- clients with other difficult interpersonal styles
- clients who have competing models for change
- clients with more and more problems
Challenges that originate with the client: Lack of adherence to treatment
- not attending sessions, being late. not completing homework, struggling with the structure
- different types of non adherence have different causes, and it is important to determine the problem before we generate solutions
- is problem one-time occurrence or part of a pattern?
- does client have skills and resources needed to follow through?
- have you done sth do undermine the homework, such as forget to ask about it?
challenges that originate with the client: methods to facilitate adherence
- client has to understand treatment planning
- homework has to make sense to and be understood by the client
- use appropriate language, repeat things
- ask how likely it is that the client will finish homework, if less than 60/70%, change assignment or make it easier
- use different types of homework
- write the homework down
- be clear about time, if client is late, do not extend the session, even if you can
- assign homework to yourself at times (e.g., finding an article for a client), follow through with your homework
Challenges that originate with the client: clients who are overly eager to please
- ideally, clients not only value the therapist input but also take a collaborative role in therapy
- if their compliance is to please you rather than to make changes for themselves, set up behavioural experiments in which they can deliberately try to displease you
Challenges that originate with the client: clients who are demanding, aggressive or angry
- provide feedback: people who express after are probably least likely to receive feedback from others in their lives, as they may be intimidating
- do not tolerate verbal or other forms of abuse from your clients: state immediately that this is not acceptable
Challenges that originate with the client: clients with other difficult interpersonal styles
- e.g., overly dependent, very quiet, intrusive, complaining, negative
- work to develop your own self-awareness and listen to your own automatic thoughts
- how do your reactions fit with the original case formulation? is there any chance that your own reactions are being communicated to clients, so that the pattern has become self-fulfilling?
Challenges that originate with the client: clients who have competing models for change
- sometimes clients don’t “buy into” the CBT model
- clients beliefs about the causes of their problems should be treated just like any other belief, they may be addressed in therapy with common cognitive strategies, such as cognitive restructuring and behavioural experimentation
- try to ensure that clients do not receive conflicting messages from other practitioners whom they are seeing
Challenges that originate with the client: clients with more and more problems
- always remember to set an agenda for each session, respect your clients input if they wish to discuss additional topics, but set a time limit for each one
- provide feedback on deviations from the agenda to ensure that clients are aware of the pattern
- give 10 minute warning
crisis
emotionally significant and very distressing event that does not necessarily include serious physical or life-threatening danger
emergency
imminent risk of serious harm to self or others in the absence of an intervention
guidelines for dealing with crises and emergencies
- increase activity: become more directive, use closed questions, be specific
- build in more support: make yourself more available, more frequent sessions or telephone contacts, access to other services, other people
- provide clear written instructions for plans made
- environmental interventions can delay or prevent a client from acting on impulses, e.g. remove risks, increase social support
- make short-term plans with the client (immediately after the session)
- consider hospitalisation
- document everything
challenges that originate with the therapist (4)
- difficulty with adherence to CBT model
- therapist “imposter syndrome”
- therapist stress and anxiety
- therapist fatigue or burnout
challenges that originate with the therapist: difficulty with adherence to the CBT model
- esp if you have training in other theoretical orientations, you may be tempted to incorporate other models
- have a supervisor or college observe your work and rate the sessions with the cognitive therapy scale
challenges that originate with the therapist: therapist “imposter syndrome”
- lack confidence or doubt your ability
- a dysfunctional thought record can help to assess and evaluate such thoughts. challenge your own cognitions with available evidence
- separate unrealistic thoughts from practice that is outside your level of competence
- use peer consultation and supervision
challenges that originate with the therapist: therapist stress and anxiety
- monitor your stress levels to ensure you do not suffer negative effects from work
- practice regular self-care strategies: time management, cognitive, emotional, and behavioural self-care
- a focus on the positive aspects of professional life, rather than the negative ones, helps you to be a better role model for your clients
