Much has been written about the methods that comprise cognitive behavioral therapy (CBT). There is an abundance of research supporting CBT’s efficacy in treating a range of psychological maladies across a variety of groups (age, gender, ethnicity, etc.). As such, CBT is more accurately described as an entire set of psychotherapies, with key features in common but also demonstrating differences depending on the problem and person being treated, that have been designed and tested to meet the highest standards of care.
Over the past few decades, great strides have been made in developing CBT so that it helps people even when they demonstrate psychological difficulties on the more serious side of the spectrum, such as chronic mood issues, suicidality, debilitating anxiety, addictions, posttraumatic stress, eating disorders, and many other areas of mental health concern. Furthermore, the field is always improving, owing to the CBT tradition of refining and researching new ways of delivering care. Although CBT is not a magic “cure,” it is a powerful psychological technology that is helping more and more people, providing ever-increasing hope for even better outcomes in the future.
It is easy to think of CBT as comprising a set of “techniques,” mainly because there is indeed a set of core methods that are most often associated with this modality that have been identified as being key components in helping people to cope and live more effectively. The list below is just a sample of such techniques, all of which have been described in great detail in CBT texts and CBT treatment research protocols:
These are just some of the CBT methods that can be used effectively, not only in the therapist’s office but also as part of homework assignments—another powerful part of treatment that improves people’s sense of self-efficacy, consolidating their memories for the interventions and their skills in performing them, and leading to good maintenance of therapeutic gains.
Additionally, the CBT literature is clear that the therapeutic relationship is an indispensible part of a positive, efficacious intervention, as is a well-conceived cognitive behavioral case formulation. This is where CBT begins to go beyond techniques and into the realm of the therapist’s personal qualities, thinking style, interpersonal manner, and skills in listening, understanding, and communicating. CBT is not delivered by machines, and it does not come in prepackaged “doses” that are passively “taken.” It is delivered by fellow humans called “therapists,” a rather diverse lot of individuals with varying years of clinical experience and training histories, as well as individual personality characteristics that naturally play a role in their competency and expertise in conducting CBT. What are the qualities of therapists who are most likely to be highly competent? What should people look for in a therapist so as to be confident that the CBT they are receiving is top-notch care?
Most people think of competency and expertise as being related to training and experience, and there is more than a kernel of truth to this assumption. When a therapist is licensed, board certified in cognitive behavioral therapy (e.g., via the American Board of Professional Psychology and/or the Academy of Cognitive Therapy), has a substantial history of treating people and supervising trainees, and has a track record of publishing and lecturing on CBT, there is a good chance that this therapist will be knowledgeable and effective in the clinical sphere. However, there is evidence that even novice practitioners can deliver CBT very competently if they are well-supervised. Therefore, there is more to competency than repetition of methods and recognition of patterns over time.
What are some of the habits, attitudes, and personal qualities of therapists that amplify their competency and help get the best clinical results, whether they practice CBT or any other evidence-based treatment? The following may seem obvious, but they warrant more discussion and attention than they typically get. If the information below simply validates and reinforces what you already do as a therapist, I will have accomplished my goal with this post. Here is a sample list of suggestions, with some accompanying commentary:
Show respect for a person’s time: Make a concerted effort to be on time for sessions, to stay focused on the person in the session (e.g., rarely attending to your incoming calls, messages, or other distractions), to give them their full allotment of session time, and to try to see them as soon as your schedule will allow. Return their phone calls as promptly as you can, and be understanding when their legitimate life demands make it difficult for them to attend sessions and/or to do their therapy homework as regularly as would be optimal.
Do your homework and be organized: Be a good role model for taking care of business, being prepared, and being up to date on a person’s situation. This includes taking good therapy session notes, reviewing those notes so you are aware of and conversant in the matters that are on the person’s agenda, following through with extra-session tasks such as consulting with the person’s other practitioners and releasing records when requested, and being willing to review the person’s homework assignments as part of your own homework. Anything you can do to facilitate your memory of the details of the person’s current life and history (including the names of family members, important events in their lives, and noteworthy things they said in previous sessions) is very powerful in conveying the message, “I value you as an individual and I am providing a treatment that is focused on you, not just your diagnosis.”
Be professional, ethical, and respect cross-cultural issues: This covers a broad area, including speaking to people in a caring, supportive, confident tone, maintaining professional boundaries while still being friendly, attentive, and personable, going over the details of informed consent, explaining both your role and the person’s role in treatment, handling uncomfortable requests in a calm way that is not sanctimonious, speaking in a way that shows self-respect and respect for the other person, and being sensitive and responsive to his or her cultural identity and related issues.
Don’t just provide instructions; provide hope and inspiration: In thinking back to our school days, most of us can remember at least one teacher who was particularly adept at inspiring us to learn and to get the best out of ourselves as students. Be like that teacher when you treat people. Many people feel lethargic, distracted, helpless, and hopeless. It is not enough for us simply to provide instructions in a neutral tone. We need to “lean in” and speak in a way that gets their attention, promotes hope, and that expresses confidence in them. Express a commitment to help the person even when he or she has difficulty making a commitment to treatment. Give positive feedback even when people can’t believe it themselves. Be a role model for persevering in the face of obstacles and adversity, and for not giving up. Share some appropriate humor at the right time to make people smile and laugh, and to add some positive energy to the therapeutic dialogue.
Be open and eager to learning: One of the most rewarding aspects of being a therapist is meeting so many people who have so much to teach us. We can provide people with an education about using CBT effectively in their lives, but they provide us with lessons about life itself. Don’t just be aware of and open to the idea that people are often our teachers, embrace the idea. It is very empowering for people when their therapists thank them for sharing their knowledge and wisdom, and it enriches the therapist—both in his or her personal life, but also in terms of being that much more aware and sensitive toward a diversity of people in the future. It also demonstrates a respectful humility that amplifies the validity and meaningfulness of what therapists communicate when they do show confidence and authority in teaching CBT methods to people.
Find the “picture that is worth a thousand words”: A little bit of creativity can go a long way in therapy, especially if it makes a positive impression on people and helps them remember important concepts for the long term. Using metaphors, analogies, images, hypothetical questions, and stories with which people can personally relate are powerful learning vehicles. When therapists make it a point to pay attention to the things that matter to people most (and that define them as individuals), such as their hobbies, their profession, their cultural practices and beliefs, their most important relationships and memories, and their views about life and the world, the therapists are in a position to give feedback that deeply resonates. Brief examples include:
In sum, CBT is a powerful technology for psychological change, but the human element is part and parcel of CBT methods. Competent CBT practitioners know how to use the core techniques that have been demonstrated to be efficacious, but they magnify the positive impact of these methods via their personal qualities, habits, and attitudes that communicate care, convey accurate understanding and respect, and inspire people to remember and use the most important aspects of treatment for the long run.
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