Right?

There is currently an insidious trend among clinicians, slowly swelling like groundwater after a storm. A way of presenting information that seems on the surface to be oriented toward building a shared understanding with our clients, but that in fact helps to shut down their thoughts, reactions, or corrections. Right?

I have been surprised recently by how often I hear this question at the end of statements by therapists. It usually follows a statement of fact, in which the person speaking assumes that the listener agrees. I have seen it occur in academic or clinical talks presented to large audiences of clinicians, in supervision, therapy groups, and even when speaking directly to individual clients.

When you get depressed, you don’t want to do anything, right? You just want to lay in bed all day.

So your child is using these outbursts to beg for attention, right? That’s the only way he knows how to get it, right? So you need to work on shaping that behavior by reinforcing positive behaviors and ignoring negative ones.

When we haven’t been sleeping well, we tend to engage in behaviors that cause further problems with our sleep, right? Like lying in bed awake for hours even when it’s clear that we’re not that sleepy. This can actually make our sleep worse. Does that make sense?

This way of speaking is epidemic in clinical work, whether we are speaking to our clients or our colleagues. And yet despite its popularity, there are some significant problems associated with this approach to checking in with our clients (many of which have to do with the fact that most people are not actually using it to check in).

So what is wrong with ‘right’?

What does asking ‘right’ at the end of a factual statement pull for? If you attend any sort of talk or presentation in the next few weeks, notice if the speaker uses this technique and then pay attention to the response. You will almost always see a wave of head-nodding after ‘right’ is tacked on to the end of a sentence. (Particularly if you are in an audience of fellow therapists – we love to nod along!) Why is that? Because ‘right’ encourages you to agree. It essentially plants the idea of agreement into your mind. Now imagine sitting in that same audience and when the speaker says ‘right’, look for the number of people shaking their head in disagreement. It will be incredibly rare. It’s very difficult to disagree when someone says ‘right’, even when we know this statement does not apply to us.

So what does that mean for therapy? It means that when we make a statement like the first one above about the consequences of depression, we’re assuming that our client has the same reaction to feeling depressed as many other people. But maybe that’s not true, maybe the client still engages in regular activities but she is so out of it and withdrawn that people in her life have started to assume that she is angry with them and have backed away from their relationships, isolating her, and leading to increased depression. The outcome may be the same as laying in bed all day, but the behavior is very different. And if I as the therapist don’t stop to check on that, I can end up suggesting an intervention that is counterproductive to the client’s goals.

Perhaps I go for the standard intervention of assigning behavioral activation for homework. I encourage my client to engage in as many activities as she can with an emphasis on mastery and pleasure (perhaps I even throw in another ‘right’ – we usually feel better once we’re up and about, right?) . Now I’ve suggested she engage in the exact behaviors that are already leading to such problems for her. She’ll continue to visit friends and go to work, all the while exhibiting a withdrawn and disinterested attitude that will further alienate her loved ones and continue the cycle of depression. If I had checked in on her actual behavior and developed hypotheses about it’s function, I would have suggested a very different intervention. Instead, I assumed, checked in nominally without actually doing so, and exacerbated the client’s difficulties.

‘Right?’ can lead us to make unhelpful assumptions under the guise of checking in with our clients.

As behavioral and cognitive therapists, we need to understand the specifics of our client’s behavior and then develop conceptualizations that assess what function those behaviors are serving in our clients’ lives (in other words, what is reinforcing those behaviors and how can we develop other types of reinforcers that will reward and therefore increase more effective behaviors?). Checking in with clients about their behaviors and the function those behaviors serve is a good thing! Checking in to make sure clients understand the rationale for completing a homework assignment or are following the psychoeducation we’re providing are also very good things! We just need to make sure we’re doing it in a way that encourages the client to give an honest response that will provide us with useful data, not generic head nods based on social convention.

In addition to ‘right’, there’s another question that therapists commonly use to ‘check in’ with clients that can have many of the same downsides. “Does that make sense?”

This question also pulls for an affirmative response (head nodding or ‘yes’). It can lead us down similar paths of assuming our clients are on the same page that we are, only to find out later that we were reading an entirely different chapter.

So what can you ask to check for understanding or conduct a thorough assessment of your clients’ behaviors, thoughts, emotions, and struggles? The solution (which many of us already know but can still sometimes struggle to implement consistently) is to use open-ended questions. What’s tricky here is that a question like ‘right?’ may feel open-ended because it’s broad and vague. But questions that pull for a yes/no response aren’t open-ended, and ‘right’ and ‘does that make sense’ often function more as verbal tics than as true questions seeking an answer.

Open-ended questions are those that (1) genuinely require an answer, and yet (2) don’t pull for a particular answer.

What happens for you when you get depressed? What are your typical behaviors? [Asking the client for their specific behaviors rather than assuming that they engage in the same behaviors as many other people experiencing depression.]

And what do you think happens for your child when he’s tantruming? Are there any benefits to that behavior for him, in terms of the response from your family, friends, or his teachers? [Assessing the client’s perspective on the function of the behavior. While you might have your own hypotheses, asking the client – rather than stating your hypotheses as fact – can help to elicit additional information that you may not have otherwise known.]

I’ve just reviewed a lot of information about sleep and insomnia – what did you hear me saying? What are you taking away? [Asking the client to share the specifics of what they heard with you rather than asking whether what you said made sense, which pulls for them to say yes regardless of how much they are actually tracking with you.]

Do you have the tendency to lean on ‘right’ and ‘does that make sense’ in place of open-ended questions? (I know that when I’m rushed or stressed, I tend to hear ‘does that make sense’ fall out of my mouth, usually after a long period of one-sided conversation with little input from the client.) If you notice this in your own work, try to pick one of these questions and focus on catching it this week. When you do, try to replace it with an open-ended question and see what you get in response. And, as always, let us know how it works for you in the comments!

 

Unanswerable Questions

I’ve been thinking recently about the perils of answering questions as a cognitive behavioral therapist. Not personal questions, necessarily – I think we all know that answering those sorts of questions from our clients can backfire in any number of ways. I’m referring more to the bigger, broader questions clients may wish to have answered, the kind of questions that bring someone into therapy in the first place.

What is wrong with me? 

Why is this happening to me?

How can I become someone different/better/not so afraid?

Cognitive Behavioral Therapy (CBT) as created and practiced by Beck suggests that therapists assume the role of a curious guide, helping the client to uncover evidence for and against their beliefs, relentless in the search for truth. This approach inherently assumes that truth really exists, that there is a right answer which can be uncovered through careful sleuthing.

And while the search for truth is often useful in therapy, there are times when it falls short. There are times when questions simply cannot be answered.

Assuming that every question has an answer sets the client and the therapist up for failure.

It means that the client will search and search for some objective fact that will explain their pain away. It means that the therapist is expected to provide an answer should the client find themselves unable to reason it out.

But we all know that not all questions have objective answers that can be discovered through careful reasoning. And we all know that sometimes even careful reasoning will not eradicate a deep, abiding belief. In these moments, it is not helpful to pretend that facts (intellectualized, rational facts) will hold up against the fire of emotion that burns beneath a question like “What is wrong with me?”

So what is the alternative? How do we as behavioral and cognitive therapists let go of our role as calm, rational expert? And when does it make sense to do so? I would argue that the therapeutic stance encouraged by Acceptance and Commitment Therapy (ACT) provides a helpful means of addressing unanswerable questions in a way that is helpful to both client and therapist. ACT views the therapist as an equal to the client, just another human being trying to get through his or her life. Which means that when a client asks a question to which we don’t know the answer, it’s actually helpful from an ACT stance to acknowledge our ignorance.

In doing this, we’re actually validating the client’s perspective more than if we tried (and failed) to give a factual answer or led the client through a series of Socratic questions to help them uncover an answer themselves. Rather than setting ourselves up for failure and setting our clients up for disappointment, an unanswerable question can become an opportunity to connect around the pain of human existence, the frustration of not always knowing why things happen to us or how our lives turned out a certain way.

What is important about this is that we don’t retreat to the unanswerable question defense in response to every challenging query. That is doing our clients a disservice in the same way that pretending to be an all-knowing expert is doing them a disservice when they (and we) come up against our human fallibility. We need to help our clients answer the questions that can be answered. But we also need to be wise about when a question is simply beyond the capability of anyone to truly understand. Why do certain people get schizophrenia? What makes someone feel completely incapable of managing their own emotions? We can provide facts and figures, but ultimately these questions are bigger than that. These questions are essentially asking what we all ask ourselves from time to time – why am I different than other people? Why do I feel this pain? Why does life hold such a mix of joy and sorrow? And why are there times when I seem to feel that sorrow more acutely that other people?

There are no answers to the why me question, other than to understand that asking it is part of our experience of being human. It is important as therapists to recognize that we are in that experience just as much as our clients and to recognize when our desire to appear intelligent, professional, or “above it all” can hinder our work. We can use unanswerable questions as a moment to connect, to share the sadness, the confusion, the pain of being human, rather than as another example of why we’ve earned the fancy degrees hanging on our walls.

Of course, facts and skills are still useful. If someone wonders why they have such a hard time controlling their emotions or why they are experiencing distressing symptoms of a mental health condition, we can provide psychoeducation and teach behavioral and cognitive skills to help deal with these concerns. However, validating the emotion that is central to broad, unanswerable questions, and using that emotion as a chance to truly connect with our clients, is central.

Unanswerable questions, though they can sometimes feel like a challenge or a panic-inducing test, are actually a gift. And if we take a deep breath and admit the truth – that there may not be an answer, that life is hard and we all (even therapists) wonder why and how things turn out the way they do – we can use the moment as a chance for both client and therapist to grow. With this approach, the unanswerable question becomes a way to help our client be heard and understood.

 


Example Transcript: Unanswerable Questions

Client: I just don’t get it. What is wrong with me? Why am I like this? I try so hard, but everyone else seems to get how to manage all of this and be normal, and I just can’t.

Therapist [nodding, leaning toward client]: Yes, you have worked so hard, and yet you still carry all of this pain around with you.

Client: Yeah, but I’m seriously asking – why am I like this? You tell me because I have tried and tried, and I can’t figure out why I can’t just be normal.

Therapist: Honestly, I wish that I could tell you why things are like this. I wish I could explain why any of us as human beings struggle with being in pain, with feeling confused, with feeling separate from other people. But I think you and I both know that there isn’t a factual answer I can give.

Client: It’s so frustrating though. Like why do some people seem to struggle so much more than others? It’s not fair.

Therapist: No. It’s not fair at all. And it hurts. There’s a lot of frustration and sadness there.

[You should allow space for silence throughout this entire exchange, but certainly when you get to a place where both you and the client are feeling the pain of what the client is alluding to – the pain of human existence that cannot be escaped. It’s important not to rush to provide an answer, or facts, or throw skills at the client in a moment like this. It’s important not to try to fix, but just to experience this emotion with the client.]

Client [after a minute or two of silence]: I just don’t know what to do.

[Now the client has turned from the pain itself to looking for a response to the pain, a real shift. You have a choice in this moment. If it feels like this is an avoidance move, then it’s usually most helpful to redirect to the emotion with a statement like “Notice how your mind is trying to search for a solution right now, how it’s trying to pull you out of the pain. But I think that pain is telling us something important about what this is like for you.” This will help let the client know that you’re going to be hanging out with the pain a bit longer, not to be punishing but to help the client really experience what is there, to process it. However, if it feels like the client has truly had some time to experience the pain and that he or she is ready to progress to the more tangible questions that do have answers (“how do I approach my life in a way that is meaningful to me, even with this pain?”) then you can progress to psychoeducation or teaching skills. If you like, you can do both: acknowledge the pain once more, and then pivot to talking about practical interventions.]

Therapist: And this might not be something that you can fully “do” something with, feeling abnormal or different from others might be a part of your experience, a part of being human, something that we all struggle with. And I think there are some ways we can work on skills to help with managing difficult emotions that might help you connect a bit more with the people you want to be close to.

A Genuine Question

A colleague and I were recently discussing a question that seems to come up often in behavioral and cognitive therapies. It can be used with clients at any stage of therapy, and it’s an inquiry that few people in our daily lives ever really ask, meaning that it holds a certain level of power and punch within a clinical setting.

So, how has that been working out for you?

In therapy (as in life), we usually know the answer to this question before we ask it. Our clients have come to us for a reason, the reason usually being that they want things to be different. But how often have you or I or any of us wanted to put the work in for things to go differently? Sometimes, occasionally, rarely.

As human beings, we are essentially optimized for stasis. We figure out something that gives us an adequate amount of short-term rewards with not too many long-term punishments (or at least, punishments that we won’t have to experience for such a long time that they are barely a shadow on the distant horizon), and we stick with whatever it is. Even with evidence to the contrary. Even with our family, friends, colleagues  (and our own minds!) telling us it’s a bad idea.

You know that doughnut is bad for your cholesterol. 

I should be getting out and socializing more, but I’m just so tired after work. 

You are going to have to learn how to control your anger one of these days.

The pull of inertia is strong. Which means that even among clients who come into therapy looking for concrete changes in how they behave, how they feel, or how they interact with their feelings, we are likely to hear some ambivalence.

There are entire therapies devoted to this very topic (check out resources on Motivational Interviewing if you haven’t already). But without delving into a whole treatment, the question above can offer a means of engaging our clients on the issue of change vs. inertia effectively. However, as with most elements of behavioral and cognitive therapies, the question itself is not as important as how you ask it.

The critical thing is that the question has to be genuine. It’s very, very easy to have a question like this edge into sarcasm, particularly if you already have a sense of how something is working (or more likely, not working) for your client. For example, let’s say a client has come to you to work on longstanding symptoms of depression. He might have a job, but spends much of his extracurricular time in bed, avoiding anyone or anything. And while this choice feels better to him in the moment than getting up and interacting with the world, his experience is one of deep loneliness, shame, and regret. He wants to be engaged in his life, wants to have friends, wants to feel that he is really living rather than simply existing.

Being the good cognitive behavioral therapist that you are, you might incorporate some behavioral activation into your work together, encouraging the client to try some new activities, to spend just a few minutes each day out of bed and engaged in his life. Some clients with persistent depression (it’s rare, but it could happen) might say, “Of course! Wow, thank you so much for this idea! I will start talking to more people and participating in more activities as soon as I leave the session.” More common (much, much, much more common) is some variation of the following: “I don’t know. I feel so tired and exhausted at the end of the day. All I want to do is sleep. And on the weekends I need to catch up on my rest or I’ll feel even worse next week. And when I’m with people, I can’t have fun anyway, so there’s really no point. Even when something really great is happening, it’s like the part of me that wants to enjoy it is trapped behind a thick, steel door that won’t let me feel any differently. I’d rather just be in bed.”

This is where the question comes in. First, start with validation. Validate the experience of not wanting to do anything, of not feeling enjoyment even when the client does engage in something. This experience only makes sense for someone who is depressed, and we can probably all think of times in our own lives when we have wanted to spend some time dozing by ourselves, when the world seemed like too much to handle and retreat was significantly more appealing. We want to truly validate the client from that place, the place of visceral understanding (which we all have – we’re human after all) of what it’s like to want to escape the world and especially the people in it. As always, tone is important. The best approach is to actually connect with this experience and this feeling in your own life and convey that sense of lived understanding through whatever tone is most authentic to you. I usually say something like, “Of course. Of course you don’t want to get out of bed. Of course you don’t want to interact with others. You feel absolutely terrible almost all of the time, and being around other people only reminds you of what you don’t seem to be able to do right now, which is feel happy or connected or joyful.” My tone usually takes on a feeling of passion in a statement like this, mainly because what feels most authentic for me is to try to connect to the power that my client’s sadness and isolation holds over his or her life. However, your tone (and certainly your word choice) should be specific to whatever is most authentic to you. The important thing is to start by just validating. It’s easy to jump into problem solving or convincing, but the validation is key. It lets the client know that you aren’t just sweeping their objections away (which is inherently invalidating). Instead, you’re genuinely trying to understand what makes this so difficult for them at this moment in their lives. Usually, clients will respond to validation by either reiterating some of the points they made previously about their difficulty in engaging in more activity or they will in some way acknowledge the emotional component of this struggle. “Yes, it’s been really difficult for me to do anything at all” or “Yeah, it sucks. All I want to do is be by myself and not have to see anyone.”

Now, you actually ask the question. “So, how has that been working out for you?” or “So, how has that worked for you?” What is critical here is that you ask this question in such a way that communicates you genuinely want to know the answer. This is more than just highlighting the discrepancy between what they’re saying right now about the difficulties of change and what they said in the past about how much they want to make these changes. This is a question that needs to come from a place of curiosity. Because there are ways in which this IS working for the client. Otherwise, he or she would not be engaging in this behavior. In the case of our example client, he is getting something real from laying in bed all of the time, and we need to be thinking of what it is (and including this information in our conceptualization to guide our choice of intervention). Some guesses: relief from the constant reminder that he is cut off from others and from most positive emotions, a bit of peace and quiet, a chance to forget that his life is not going the way he wants it to, connection with the world through passive means (TV, news, scrolling through Facebook or Twitter or Instagram), physical comfort associated with lying in a comfortable bed. Whatever he’s getting (and it may be more than one of these things or something else entirely), it’s important that we understand what it is while also helping him place this reward in the context of the life he wants for himself.

When asking this question, I have found (and you may certainly find something different, depending on your own style and presence in the therapy room) that a gentle but straightforward tone works best. Veering into sarcasm or stridency is not effective. I have also found that it is helpful to make eye contact as you ask the question. You want to connect with the client in this moment, cutting through any urges to defend themselves with more reason-giving or avoid supplying the true answer, and holding steady, open eye contact is usually an effective means of doing that.

The mood in the room usually shifts in this moment. If you’ve asked the question in a gentle way that seeks a true answer, there is a sense of honesty and forthrightness that is often different from what came before. We’re no longer talking about what’s easy; we’re talking about what’s true. Yes, it’s easy to lay in bed all day. But what’s true is that our client is deeply lonely. Usually, this question can help elicit that truth.

Some clients will laugh a bit. Others might stare at you for a moment. As I mentioned before, this is not a question that most people in our lives ask with the expectation that they will receive a genuine answer. It may be asked sarcastically, but most often our loved ones don’t ask any question at all. Instead, they tell us directly the many reasons that our choices have not been leading us down the right road in their opinion. This pulls for us to defend ourselves, which is why that’s usually the first response we get in the therapy room as well – a list of reasons why making a change is impossible. But this question can open up something different. We all have reasons why we don’t do more of some things and less of others. Asking a client how well those reasons are working for them helps to cut through the reactionary responses and can lead you toward something real. Clients will usually give an honest answer (sometimes only after I clarify that yes, I am seriously asking how it’s working, and yes, I’m assuming something about it does work, at least in the short-term). This can give you the space to ask them to try something new.

As always, buttressing the request for new behavior with validation is helpful. In this moment, I usually attempt to preserve the quieter, more honest mood that we initiated a few moments earlier by keeping my voice relatively low, and my tone warm but straightforward. “So in many ways, this behavior is not working for you. Laying in bed all day feels safe in the moment and keeps you from all of the reminders of what you don’t have right now, and at the same time, you know that you want something different for your life. You want to be involved and engaged with people who are important to you. You want to be finding enjoyment and meaning in the process of living, rather than just existing.” Usually this is a bit of an extension from what the client has said. If I ask our example client how laying in bed all day is working, and he tells me that it’s not really, that he’d like to have more friends, then I make a statement like the above in order to connect him to something more powerful and meaningful than someone to occasionally eat dinner with. I’m attempting to connect him to a fuller and richer picture of his life, since we know that’s probably closer to what he actually wants (it’s what we all want).

After a statement like this, I will then transition to actually asking for some new behavior (in this case, a bit of behavioral activation). However, I think this is a moment where you usually have enough room to have the client generate ideas for what to do next. Hopefully, they are feeling connected to what they truly want and slightly less attached to their many reasons for not engaging in challenging, stressful, not-immediately-rewarding behavior. So I often ask them something like, “So what would you like to do this week?” or “So what would you like to do next?” You can get more specific if needed (“What would be one step you could take this week to get closer to that goal of being more connected to others?”), but an open-ended question will at least start you down the road to making a specific plan, while still allowing the client to feel connected to this larger sense of what’s important to him and what has not been working about his current way of doing things. If things have gone well, you can often take a backseat here, and let the client generate some ideas with just a bit of shaping and guidance from you. Depending on the client, you might also occasionally intersperse some additional validation about how this might be challenging (it’s a whole new way of doing things, after all), and that you can see how important taking these challenging steps is to the client in terms of helping him get closer to the life he imagines. The theme of this intervention really is accurate, genuine validation interspersed honest discussion to hopefully open up a bit more space in which the client can experience some willingness to try something new.

I’ve included an example transcript of how this sort of conversation might go in the space below, and as always I’d love to hear your thoughts/reactions/questions in the comments, particularly if you’ve been able to give this approach a try!

 


Example Transcript: Asking the Question

Therapist: So I’ve been thinking that it might be helpful to work on planning some activities for this week. We spoke before about how doing more fun and enjoyable things can help with feeling down and can also help get you more engaged with things that you like. So what kinds of things would you like to do this week?

Client: I don’t know. I feel so tired and exhausted at the end of the day. All I want to do is sleep. And on the weekends I need to catch up on my rest or I’ll feel even worse next week. And when I’m with people, I can’t have fun anyway, so there’s really no point. Even when something really great is happening, it’s like the part of me that wants to enjoy it is trapped behind a thick, steel door that won’t let me feel any differently. I’d rather just be in bed.

Therapist: Of course. Of course you don’t want to get out of bed. Of course you don’t want to interact with others. You feel absolutely terrible almost all of the time, and being around other people only reminds you of what you don’t seem to be able to do right now, which is feel happy or connected or joyful.

[Tailor your validation to what works for you and fits with your style. For me, this would be said with some level of passion, in an attempt to connect with the seriousness with which the client views his barriers to more activation.]

Client: Yeah, it sucks. All I want to do is be by myself and not have to see anyone.

Therapist [gentle, straightforward, looking the client in the eye]: And how has that been working for you?

Client: [A few seconds of silence.] What?

Therapist: I’m genuinely asking. How has spending all of your time alone been working out for you?

[Really hold the eye contact here and remember to ask the question in a fairly neutral, straightforward way. You are creating space in this moment for the mood to shift, to cut through the reasons and connect over the pain of this aspect of his life. Slowing down and allowing space for silence can also be positive as you ask this question and process the client’s response.]

Client: It’s not. I hate it. It’s not what I want.

[This is probably the point where you’re thinking, it’s never that easy in real life. That’s true – every client is not immediately going to highlight all of the problems with their current approach. If the client doesn’t go right to a genuine answer of how this hasn’t been working, then I would ask the question again in a slightly different way (“So you spend almost all of your time alone. I’m wondering – how has that been going?”). I would conceptualize any sort of reason-giving at this point as a form of avoidance, which you don’t want to reinforce or get distracted by, so you want to stick to your position by continuing to ask the client to confront the truth. If the client continues to give reasons, then you can also highlight that there are ways in which this behavior IS working – it’s giving the client something. If the client agrees, then some extending can be helpful. “There are certainly reasons that laying in bed all of the time feels more enjoyable than getting up and going out. So what do we have to talk about?” Extending means that you’re taking the client’s comments out to their logical conclusion (in this case, that being in bed is a positive thing and he doesn’t need or want to make any changes). Clients will often come back with the ways in which they do actually want to change, which you can then validate before helping them to establish how they would go about making concrete changes.]

Therapist: So in many ways, this behavior is not working for you. Laying in bed all day feels safe in the moment and keeps you from all of the reminders of what you don’t have right now [validating how hard this is!], and at the same time, you know that you want something different for your life. You want to be involved and engaged with people who are important to you. You want to be finding enjoyment and meaning in the process of living, rather than just existing.

Client: Yeah, I don’t want to spend the rest of my life in bed. I want to be married again, I want friends that I care about, I want to be out doing things.

Therapist: So what would you like to do next? or So how can you start to move closer to that?

[If needed, you can progress to asking more specific questions about next steps, but starting with a broad and open-ended question helps the client to get creative and also helps him to take some of the responsibility for this new approach. Ideally, the client is generating ideas – with some help and shaping from you – and taking an active stance in making a plan that really works for him. Remember, throughout the rest of this conversation, you are validating the challenges of doing something different while also reminding the client that this is what he wants, this is important. Hopefully at this point in the conversation you have transitioned from being the one pulling the cart along to a bystander encouraging the client as he takes the next step forward.]

 

Hello/Goodbye

As therapists, we often focus on what to do once we’re inside the therapy room – how to select interventions to address various components of our conceptualization, how to reinforce homework completion, how to address problematic avoidance behaviors or intractable core beliefs. However, the conversations that go on outside (or in the doorway) of the therapy room can be just as important as those that take place in it.

Furthermore, these conversations can be tricky. As human beings, we’re socialized to engage with others in particular ways. Therapy frequently requires us to look beyond social convention to make deliberate choices that buck habit, tradition, or rote patterns of behavior; the same can be said for greeting and saying goodbye to our clients. Just as novice therapists have to learn not to change the subject or offer comforting platitudes when a client becomes tearful (both typical, polite responses to tears in most non-therapy settings), effective behavioral and cognitive therapists have to learn how to greet their clients and bid them farewell in a manner that supports the overall work of the therapy. This is a difficult endeavor, and like most tasks in behavioral and cognitive therapy, it requires us to consider the contingencies of particular behavioral choices.

For example, a common approach to greeting someone in American culture is to ask “how are you?”. We all know the range of acceptable responses. “Fine.” “Okay.” “Good.” “I’m doing well – how about you?” As visitors to the United States are sometimes surprised to learn, this question is not generally seeking an in-depth or even particularly honest response. It’s a convention, and like most social conventions, there are rules. It would be rare in American society to hear someone respond to the question “how are you?” with an answer that substantially deviates from a polite, vaguely positive response that provides minimal details of their actual well-being.

Yet, in therapy, this is exactly what we’re asking for. When we ask a client “how are you?” in the context of therapy, we don’t want the polite response – we want the truth, in all of its gory and socially unacceptable detail. Which means that it’s important not to ask this question as part of a rote greeting in the waiting room. It can be confusing for clients who may not know that we are seeking one answer as part of our work together and another on the walk from the waiting room. Asking a client how they are outside of a session can inadvertently pull for disclosures that put their confidentiality at risk (Therapy must be beginning now, even before we get into the room, so I should give the full details of what happened to me this weekend) or can create a sense of you as inauthentic both inside and outside of therapy (She doesn’t really want to know how I’m doing. Even my therapist expects me to be fine, despite everything going on in my life right now).

Asking someone how they are can also encourage them to ask you how you’re doing in response. This can create an awkward situation, since you are then pulled to give a somewhat rote, polite answer (in order to prevent disclosing too much and making the interaction about you as the therapist). Again, it’s poor modeling, and it confuses the function of therapy as a different type of interaction from the ones the client has day in and day out with his or her family and friends.

Instead of going down the “how are you?” path, it can be helpful to greet the client with a comment that conveys a similar level of interest, care, and concern for them, without explicitly using a question that is so loaded in the context of the therapy relationship. Something like “it’s good to see you” is very welcoming without pulling for an in-depth conversation in the waiting room. You might also choose to approach the greeting by asking a question (thereby engaging the client in a conversation) but choosing a topic that is more neutral than asking about their current emotional state. “How was the traffic today?” “Did you get here okay?” “What’s the weather looking like out there?” At a first session, I often ask “did you have any trouble finding us?” along with follow-up comments about the relative ease or difficulty most people have in locating the clinic in order to ease the client into a conversation. These topics can help you have something to discuss as you walk back to the therapy room, while still keeping a separation between the types of interactions you have in therapy and the more mundane topics of daily life. Depending on where you live, it can be helpful to adjust these questions to what is going on in your community, such as a recent snowstorm, the results of a local sports team’s latest game, or construction on a local highway that may have impacted their trip to see you. In general, staying away from emotionally charged topics, like politics or other newsworthy events, is a good idea during the walk to the therapy room.

Saying goodbye at the end of a session is another area in which word choice is critical. As a beginning therapist, I often said “have a great week” at the conclusion of my sessions, thinking that this was an encouraging and positive way to end meetings with my clients. However, as was eventually pointed out to me by a thoughtful supervisor, this sort of comment creates unhelpful contingencies within the therapeutic relationship. Wishing that a client has a great week includes implications about what you expect and don’t expect – namely, that you expect them to do well and feel happy and do not expect them to be sad/angry/confused/afraid/hopeless. Much like asking someone how they are, this comment is just not useful to the work that we are doing in therapy. It undermines the idea that it’s okay to have things go poorly, it’s okay to feel bad, it’s okay to struggle to complete homework, all of which are important beliefs underlying behavioral and cognitive therapy.

Similar to the greeting, it can instead be helpful to say something at the end of the session that conveys care for the client and their well-being without setting up unwanted contingencies and expectations. A statement like “good to see you” or “take care” can help communicate your appreciation for the client. I often like to follow one of these comments with “see you next Wednesday” or “see you soon” to remind the client that we will be meeting again. When clients are struggling it can be particularly helpful for them to feel a sense of compassion from you at the end of session as well as a reminder that you are there for them and will be seeing them again in the very near future to continue your work together. At a final session, ending on a phrase like “take care” as the client leaves your office can help solidify your relationship and remind the client that even though you will no longer be in contact, there is someone out there who cares about their well-being and wishes them well.

So how do you approach greeting and saying goodbye to your clients? What phrases or topics have you found helpful or problematic in the (sometimes dreaded) walk to the therapy room? How do you prefer to end sessions? Feel free to leave any tips and tricks in the comments!

Consider the Consequences

I recently participated in a team meeting in which staff were attempting to decide how to handle a behavioral infraction committed by a client participating in a structured therapy program. This client had already received the stated consequence for the infraction, but the question on the table was whether he would be allowed to graduate from the program on time or would be asked to complete additional treatment before becoming a graduate. The recent behavioral problem had led some staff to worry that the client had failed to meet the spirit of the program, and graduation was considered a carrot which would be used to motivate the client to follow program rules.

One staff member voiced concern that the client would not recognize the impact of his actions without additional consequences. Other staff argued that since the client had already received a consequence for the infraction and a change in his scheduled graduation had not previously been identified as a possible outcome of his behavior, adding this consequence was inappropriate.

So who was right?

There may not be an objectively “right” answer, but this experience reminded me of the importance of incorporating the most fundamental principle behind all behavioral and cognitive therapy into our work as therapists: contingency management. In other words, attending to the consequences of behavior and using those consequences to shape desired outcomes.

As behavioral and cognitive therapists, conceptualizations of our clients should include a focus on the contingencies shaping their behavior, and our interventions should directly target the behaviors we (and they!) want to increase or decrease.

So what does this look like in practice? First, it requires an understanding of some basic principles of behaviorism. There are two ways that consequences can function for a client.

Reinforcement is a consequence that encourages more of a given behavior. If my client completed her homework assignment, I will attempt to reinforce this behavior by praising her. “This is so great! Look at all the hard work you did on this! I really appreciate your efforts.” I am trying to increase the likelihood that she will continue to complete homework assignments in the future by applying a specific consequence that I believe she will find enjoyable: praise. Note that instead of adding an enjoyable consequence (praise), I could also remove an unpleasant consequence in order to reinforce a behavior that I’d like to see more of. For example, I might have an agreement with my client that if she completes her homework assignment, I will ask her to complete two exposures during our session instead of our usual three. Bringing in a completed homework assignment means that I will remove an experience that she perceives to be unpleasant from our session, which reinforces continued homework completion.

Punishment is a consequence that encourages less of a given behavior. If my client frequently arrives late to our sessions, I could attempt to punish this behavior by asking the client to complete a chain analysis on the chain of events that led up to him arriving late. In other words, I could attempt to reduce the frequency of his late arrivals by applying a consequence I believe he will find unpleasant. Alternatively, I could also attempt to remove an enjoyable consequence in response to his lateness, in order to punish the behavior that I would like to reduce. For example, if I normally allowed a few minutes at the beginning of session for the client to check in about his experiences throughout the week prior to getting into the the session agenda, I could let him know that we would not have that time when he arrives late.

To summarize, reinforcers increase the likelihood of a behavior occurring again while punishments reduce the likelihood of a behavior occurring in the future. You can either add a consequence to reinforce or punish (positive reinforcement or positive punishment) or you can remove a consequence (negative reinforcement or negative punishment). Here, “positive” and “negative” don’t refer to valence (good or bad) – they refer to addition or subtraction. Here’s a summary:

 

Reinforcement

Punishment

Positive

Adding a consequence which results in increased likelihood of a particular behavior Adding a consequence which results in decreased likelihood of a particular behavior
Negative Removing a consequence which results in increased likelihood of a particular behavior

Removing a consequence which results in decreased likelihood of a particular behavior

One thing that’s important to note is that your choices around how to reinforce a behavior you want or punish a behavior you’d like to reduce or eliminate depend on the client’s interpretation of your chosen consequences. For example, in the example of positive reinforcement above, I suggested that I could offer my client praise in order to reinforce her homework completion. But this will only work if my client finds praise to be enjoyable and therefore reinforcing. If she feels uncomfortable when she is praised, then praise will actually function as a punishment for her and would serve to diminish the likelihood of her completing homework in the future, since she will try to avoid being praised. This is why it’s very important to understand how your client experiences various consequences. You might have a hypothesis based on your experience in the world (“people enjoy praise”, “many clients dislike completing chain analyses”), but you’ll need to test this hypothesis with your individual client.

I once had a client who had been experiencing depression following a romantic breakup. In an attempt to reinforce getting out of the house, I asked her to engage in a pleasant activity (positive reinforcement), and we agreed that she would go see a movie that weekend. At our next session, I was eager to hear whether she had followed through on the assignment. She heaved a deep sigh and told me that although she had gone to a movie, it had been very difficult for her to sit through the entire thing. It turned out that during their relationship, the client and her partner had frequently gone to the movies together, and being in the theater actually made her feel more depressed and alone. Rather than the reinforcement I was seeking, this experience actually served to punish the client for getting out of the house (positive punishment)! I had assigned a generic “pleasant activity” without assessing its impact for this particular client. Let my mistake be a lesson: generate a hypothesis about how a consequence will function, but make sure to test that hypothesis with your specific client.

As I hope has been made clear, a focus on consequences is important not only for behaviors within the therapy session (attendance, homework completion, appropriate interpersonal behaviors with the therapist) but in the client’s daily life as well. Movement toward the client’s goals can be addressed by utilizing principles of contingency management to selectively reinforce and punish behavioral choices. For example, if your client’s social anxiety contributes to isolation and loneliness, you might help him set up a contingency around social engagement. Perhaps the client could receive a small reward for each person with whom he initiates a conversation throughout the week (positive reinforcement), such as the opportunity to watch a favorite television show or eat a favorite snack.

The hope is that natural contingencies will eventually take over. For example, the client might eventually experience a reduction in anxiety around others after having a series of enjoyable conversations; this reduction in anxiety would serve to reinforce greater social engagement (negative reinforcement). However, in the initial stages of treatment, talking to people might serve as a punishment for the client, due to increases in his anxiety (positive punishment). Your goal as the therapist is to facilitate artificial contingencies (those that are not inherently part of the situation, such as receiving the opportunity to watch a funny show after initiating a conversation) in such a way that you can overcome the initial period of discomfort until natural contingencies begin to take effect.

Some of the standard activities that we ask clients to do as part of behavioral and cognitive therapies serve as contingencies that have been shown to be generally effective for many people (e.g., activity scheduling, graduated exposure exercises,  behavioral activation). However, as cognitive behavioral therapists, we have the capacity to utilize behavioral principles in an individualized way that goes beyond what is written in a treatment manual. Using the basic principles of reinforcement and punishment, we can tailor treatment to each individual client and their needs, all within the framework of behavioral and cognitive therapy. So what behaviors would your clients like to increase or decrease in their lives? What behaviors would you like them to do more or less of within your sessions? How can you use reinforcement and punishment based on each client’s unique likes and dislikes to establish contingencies that will lead to more of the behaviors you want and less of those that are decreasing your clients’ quality of life?

 

Nice or Warm?

I recently had a rough day of clinical work. Feeling frustrated after several no shows, I consulted with a colleague about my fears that these missed appointments indicated one or more of my clients might be on the verge of dropping out of therapy. I was particularly worried because several of these individuals were engaged in evidence-based, trauma-focused treatments.

If you have ever done trauma-focused therapy, you know that encouraging the client to stay in treatment and complete the protocol is one of the most important therapeutic tasks. As clinicians and consumers of research, we know the benefits of Cognitive Processing Therapy and Prolonged Exposure, but to our clients, being asking to think, write, and speak about past traumas can be extremely difficult. So difficult that clients sometimes choose to end therapy midway through the treatment rather than sticking it out through the end of the protocol.

I have always found this to be one of the most upsetting aspects of clinical work. I’m sure we can all think of cases where we truly believed that we could help the client to reach their goals, but the client elected to end therapy before we could reach that point. While I understand it from the perspective of the client (behavioral and cognitive therapies require a lot – a lot of time, emotional investment, money, cognitive resources, etc.), it can be heartbreaking as the therapist. Especially when you are working with clients who have struggled with their trauma for years. You know that if they could just stick with the therapy it is likely that some or even most of their symptoms will diminish. But sometimes the avoidance is too strong, and clients choose to terminate.

On this day, I was worried that this process had already been set into motion. What if my clients were finding the trauma-focused work to be too much? What if this was just not the right time for them to do the work required by this therapy? What if I hadn’t done enough to convince them that the therapy would be effective?

I sought input from a colleague, hoping for validation that the clients would return, that this day of multiple no shows was a fluke. As we talked, my colleague shared her perspective on no shows and the ease with which our therapists’ minds jump to conclusions about what a missed appointment might mean. Then, she said something that struck me. “Even if they end up dropping out, at least you know that you were nice to them.”

Hmm. I thought about that for a second. Clearly, my colleague was trying to validate my efforts as a therapist – even if clients leave before we’d like them to, we can feel confident that they have gotten to experience a positive relationship with a nice person.

But while I saw what she was getting at, the word “nice” didn’t sit very well with me. In truth, I hadn’t been very nice to my clients. They came to me for help moving beyond the painful memories of trauma and the associated emotional, behavioral, and cognitive sequelae of those memories. And what did I do? I made them remember. I encouraged them to think about, to retell, to engage with those memories, even when they hurt (especially when they hurt) as a way of habituating to them and disengaging the memories themselves from some of the emotional pain associated with them.

To me, this is not being nice. Being nice would mean never bringing up painful topics, never challenging easy assumptions. Family members can be nice. Friends can be nice. Therapists are not in a position of being nice, especially trauma therapists.

Therapists are not nice. But we should be warm.

What is the difference? To me, niceness implies that you are trying not to ruffle any feathers. You interpret the client’s social cues and you follow them. Your client becomes hesitant when talking about that experience? Fine. No problem. We’ll talk about something else. The client tears up when a particular family member is mentioned? Not a big deal. We don’t need to go there. Niceness means using your therapeutic skill of reading another person and assessing where they are at to make sure that you don’t upset them.

Warmth is something else entirely. A warm therapist moves toward emotional pain in the room and engages in this movement from a place of compassion and caring. Your client begins to cry when you talk about what is going on for her at work? Rather than shy away from it, let’s talk about what is happening that is feeling so upsetting for her. And let’s do it in a way that illustrates to the client that we are coming from a place of caring, of understanding how painful this is and of choosing to go there anyway in the service of the life the client really wants for herself.

Warmth is a series of behavioral choices made by the therapist.

Warmth goes beyond what we choose to talk about in the session, but encompasses how we talk about that subject. Warmth means conveying through tone of voice, body position, eye contact, and word choice that we are present with the client and care about what is happening for them.

Warmth means that the caring we have for that client is coming through in our voice. Our tone is not flat or merely inquisitive. Our tone illustrates the caring that we feel. We could be saying anything – even something very difficult for the client such as “I need you to continue with this exposure” – and our tone illustrates that we’re saying it with a client-focused purpose in mind.

Warmth is also conveyed in body position. If I am slumped back in my chair or (more commonly) sitting up straight as a board, the picture of professionalism, I may not be conveying warmth. What may be needed in the moment is orienting toward the client, even leaning in closer to them to illustrate that I am here for them, that I can see something important is happening and that I am with them in their pain. This shows that even while I am holding a firm line (this is painful and I’m not going to let you get out of talking about it regardless), I care. I’m attuned. This is a human interaction, not just the implementation of a protocol.

Eye contact, or lack thereof, can be a mechanism of warmth as well. Looking at the client when they are tearful shows that you are present – you aren’t scared of this emotion, which can help to normalize that experience for the client. In our daily lives, friends and family so often look away when we cry. Just allowing space for that pain, honoring it with your attention, can be a powerful intervention that shows how much you care. Lack of eye contact can also be a move toward warmth. Looking down to give the client a moment to him or herself can be meaningful, can show that you are willing to wait, that we don’t have to hurry up and move on from this emotion.

Regardless, the way that you utilize eye contact is important. Holding eye contact with empathy is different than looking at someone with panic (This is too much emotion – what do I say to the client next?!) or blank curiosity (Wow, why are you so upset? Is this really that big of a deal to you?) or boredom (I know I’m supposed to give clients a minute when they cry, so let’s get through this and move on.). Similarly, lack of eye contact can be interpreted differently depending on body position and other non-verbals that affect the feel of the experience in the room. For example, boredom (if your gaze is wandering all over the room or looking at the clock) versus engagement if you are looking down at a spot between you and the client, present but slightly removed, allowing them to have a moment to themselves. Spend some time with a mirror examining how your gaze appears. If possible, videotape yourself with clients (or with a friend for practice) to see how your non-verbal behavior comes across. It is not uncommon for there to be a disconnect between how you are feeling internally (caring) and what is coming across to the client (confusion, anxiety about what to say next, disinterest, boredom, professional detachment) based on your non-verbal behaviors.

Finally, word choice is, of course, critical. It is so important to validate pain. Again, nice means that we don’t talk about pain, we politely pretend that it is not there. Warmth means I will hold your feet to the fire, but I will do so in a way that acknowledges how difficult this is for you. “I know this is so hard to talk about, and I’m going to ask you to keep going.” If the client is having difficulty moving forward in talking about a painful topic, a mix of open-ended questions and commands can be helpful. “What is showing up for you right now?” “Tell me more about what happened.”

Warmth may feel like something that you either have or don’t, but it can absolutely be learned. What is important to remember is that, like so much of therapy, it is about much more than what is written in the protocol or being a generally nice or pleasant person. Warmth is about caring for your client and conveying that care through your verbal and non-verbal choices. Warmth is what kept the clients who did not show up for our therapy sessions on that recent rough day from dropping out entirely, despite the fact that trauma treatment (or any therapy for that matter) is not always nice.

How do you move toward warmth with your own clients? Do you agree that good behavioral and cognitive therapists can be warm without necessarily being nice all of the time? How might you think about experimenting with your non-verbal behavior in order to foster a feeling of warmth in the therapeutic relationship?

The Horizontal View

I was browsing an online psychology forum this week when I came across a post about seeking therapy while on internship. The writer stated that he was feeling overwhelmed by the demands of internship training and was looking for a way to address his difficulties effectively. He was considering therapy, but was concerned about the cost and time required, as well as the desire to maintain his confidentiality given that many local therapists were affiliated with his training site in some capacity.

In reading the post, I assumed that many of the responses would be similar to my own initial reaction: of course you should seek therapy. Taking care of yourself is incredibly important, particularly when you also have a professional responsibility to take care of others. As therapists ourselves, we know how effective therapeutic interventions can be – so why wouldn’t we take advantage of this resource when needed?

Unfortunately, this opinion was in the minority.

Instead, many responses were critical, suggesting that the author must be doing something wrong if he could not handle the rigors of internship without therapy.

I was struck by the tone of these responses. Not only were most unsupportive of the author’s struggles, but there seemed to be an underlying assumption that therapy is only appropriate for certain types of people. In this view, hardworking, intelligent, and successful individuals do not need therapy. Therapists should therefore never seek treatment themselves because our advanced degrees and professional achievements mean that we have our lives figured out. If only.

This attitude only serves to prevent us from engaging with our clients effectively. Most behavioral and cognitive therapies encourage us to act as guides for our clients, leading them toward behavioral change or helping them learn to challenge inaccurate cognitions from the perspective of someone who knows better, someone who can pick out the cognitive errors or understand the reinforcement principles maintaining negative behavior. However, this stance can also promote the belief that we do in fact know more than our clients, that we are in a superior position.

What is wrong with this belief? The main problem is that it can blind us to the client’s struggles. From a superior position, it is much easier to conclude that our client is not trying hard enough. After all, we understand that the thought “I’m a failure” is an exaggeration that doesn’t present a complete accounting of her worth. In this vertical approach to the relationship, the therapist is positioned above the client.

A vertical view of the therapist-client relationship promotes sympathy. Wow, that must be so difficult for you.

A horizontal view creates space for empathy. I have felt the sucking, sinking devastation of failure, and I know the pain of trying to convince yourself that this does not represent all that you have to offer this world.

A horizontal view of the therapeutic alliance, in which the therapist and client are considered to exist on the same level, requires so much vulnerability. It requires us to show up to the session prepared to react exactly as the people we are. If something the client shares reminds us of our own experience of sadness, we feel that sadness. If the client talks about the fear of being abandoned by others, we confront whatever permutation of that same fear exists within ourselves. We don’t get to hide behind the shiny armor of professionalism or wrap ourselves in the various diplomas we’ve nailed to the wall. Taking a horizontal view is like wearing that ratty t-shirt you’ve had since 2002 instead of your best suit. It incorporates the real you, the one who has also felt pain and been lost and not known what to do.

To be clear, employing a horizontal therapeutic approach does not mean making significant changes in your external behavior. In fact, it may not be particularly visible to your clients. The horizontal view is more about how you react internally to information presented in session – the emotions you allow yourself to feel, the personal experiences you allow to be touched by what is happening in the room, the way you think about your client in relation to yourself. This internal experience is likely to impact the quality of your interaction with the client – his or her felt sense of being understood, listened to, and validated in a truly compassionate way – but it is not a prescription for a specified set of behaviors. And the horizontal view absolutely does not mean that you are telling your client about arguments with your spouse or the time you were let go from a job. This is not a conversation between two friends. But it is a conversation between two equals. Two people who have both had difficulties. Two people who have both needed help at various points in their lives.

In Acceptance and Commitment Therapy (ACT), there is a metaphor called “two mountains” that illustrates this concept perfectly. The client who has come to us for therapy is scaling a mountain. And we, as therapists, are his guides. But we are also scaling our own mountains nearby. From our vantage point, we can see obstacles and pitfalls the client is not aware of yet. But that does not mean that our experience is free of obstacles of our own. After all, we each have our own mountain to climb.

This is the horizontal view. A space from which we can empathize and therefore connect more effectively. From this space, it is difficult for judgments about the client’s supposed lack of effort or “resistance” to completing homework to wiggle their way into our minds. Instead of the role of cognitive or behavioral expert, we assume the mantle of a compassionate investigator, a person on the same team as our clients (the human team), struggling to understand and cope with the universal difficulties of self-critical thoughts, difficult emotions, and less-than-ideal behaviors (five hours of Netflix, anyone?). It is a challenging place to be. But it is a place that can bestow great benefits for our clients, and ourselves, if we let it.

So what do you think? Where along the continuum between vertical and horizontal therapeutic relationships do you tend to fall ? How might you consider approaching one of your clients from a more horizontal stance? What would need to change?

 

The Therapeutic How

In the realm of behavioral and cognitive therapies, there is an enormous focus on technique. These therapies are lauded as evidence-based because they have been tested through research. In other words, studies have suggested that these treatments work and have answered what is often the biggest question when searching for a useful clinical intervention: what do I do? As in, what do I do when someone walks through my door with serious depression? What should I do if a client is exhibiting signs of psychosis? What can I do for someone who is petrified of leaving his home?

The what question is important and immediate and so its answer is the one researchers search for and the one clinicians request. Other questions about behavioral and cognitive therapies – important but perhaps not as immediately pressing – such as for whom and when and how much are secondary. Research will get to those eventually, we tell ourselves and each other, even as we try not to think about the limitations inherent in so many studies of these therapies, studies that select a single specific diagnosis, rule out anyone with comorbidities, limit the sample to the most readily available racial/ethnic group, and focus only on individuals with a moderate level of symptoms.

So researchers have some work to do. But this blog is not meant for researchers.

Therapists are tasked with learning what to do. But we are also tasked with implementing it effectively. In other words, therapists need to find the answer to a question that is bigger than the what: how do I do it? How do I implement CBT effectively? How do I build a therapeutic alliance that will help my client with PTSD stick through this treatment? How do I conduct an exposure or assign homework or respond to grief and loss? There is the content and there is the process.

Our field has focused so much on systematizing, testing, and disseminating the content of interventions, that we have lost sight of the need to do the same with the process of behavioral and cognitive therapies.

Instead, we ask beginning clinicians to learn these skills through supervision. And while good supervision in behavioral and cognitive therapies can be an absolutely incredible learning experience, particularly around process, there is an idiosyncratic aspect to clinical supervision that leaves quite an opening for limited or even iatrogenic learning. Trainees are lucky to get really effective supervision, but many do not, and what they do receive may not be consistent across their years of training.

Which leads to the impetus for this blog. The Therapist’s Guide is intended to provide one shout into the abyss of the therapeutic how. Of course, this is a different endeavor than the one that supports the examination of the therapeutic what, which has research funding and complex statistical analyses and follows an established medical model of scientific inquiry. But the hope is that this blog can open and contribute to a conversation around how to do good cognitive behavioral therapy, how to actually implement all of these techniques we read about in our manuals. The opinions, thoughts, and musings found here are one therapist’s efforts to expand the conversation around behavioral and cognitive treatments to include not just the interventions themselves, but the work of the people who are implementing them, the work that makes therapy so much more than a list of techniques.