What problems exist in therapy? - Chapter 22

This chapter discusses problems that might arise during treatment.

What are the key steps to identifying a problem?

Problems in therapy arise almost with every client; they provide insight into problems the client experiences outside the office. Problems can be uncovered in a number of ways: By listening to clients’ unsolicited feedback, by directly soliciting clients’ feedback, whether or not they have provided verbal or nonverbal signals of a problem, by reviewing recordings of therapy sessions alone or with a colleague or supervisor and rating the tape on the Cognitive Therapy Rating Scale or by tracking progress according to objective tests and the client’s subjective report of symptom relief.

Having identified a problem, a therapist should be aware of automatic thoughts blaming the client. The problem can have different causes and ideally the therapist can show recordings of the session to a colleague to evaluate the cause of the problem together. Problems can occur in one or more of the following categories: diagnosis, therapeutic alliance, structure of the session, socialization of the client, dealing with automatic thoughts, accomplishing therapeutic goals across sessions and clients’ processing of the session content. At times, clients may feel better during individual sessions but fail to make progress over the course of several sessions. The experienced therapist, in lieu of the preceding questions, may first wish to rule in or rule out five key problem areas:

• Do the client and I have a solid therapeutic alliance?
• Do we both have a clear idea of the client’s goals for therapy? Is he committed to working toward his goals?
• Does the client truly believe the cognitive model—that his thinking influences his mood and behavior, that his thinking at times is dysfunctional, and that evaluating and responding to dysfunctional thinking positively affect how he feels emotionally and how he behaves?
• Is the client socialized to cognitive behavior therapy—does he contribute to the agenda, collaboratively work toward solving problems, do homework, provide feedback?
• Is the client’s biology (e.g., illness, medication side effects, or inadequate level of medication) or his external environment e.g., an abusive partner, an extremely demanding job, or an intolerable level of poverty or crime in his environment) interfering with your work together?

When a therapist identified a problem and depending on what kind of problem, he or she may consider the advisability of one or more of the following:

• Giving the client a more in-depth diagnostic evaluation.
• Arranging a medical or neuropsychological examination for the client.
• Adjusting your conceptualization and checking it out with the client.
• Learning more about the treatment of the disorder of the cient.
• Asking more specific feedback from the client about her experience of you and of the treatment.
• Reestablishing the client's aspirations, values and goals for treatment.
• Talk about the cognitive model with the client again.
• Going over the treatment plan with the client again. Finding out if there are concerns or doubts.
• Assessing the expectations of the client for how he is going to get better.
• Be clear about the importance of setting and reviewing action plans during sessions and accomplishing action plans throughout the week.
• Keep working on automatic thoughts, beliefs and behaviors.
• Make sure to check what the client understood from the session content and record the most important points.
• If necessary, change the structure of the session.