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.

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