4) Psychoeducation and Preparing Clients for CBT

Question 1

Is T-C relationship important, essential, and/or sufficient to affect change?

Answer 1

• T-C relationship is important for change
• T-C relationship is essential for change
• BUT T-C relationship alone is not sufficient to affect change

Question 2

What role should the clinician take in the T-C relationship in terms of…
* classical psychoanalysis
* Counselling
* CT
* BT

Answer 2

• Classical psychoanalysis: Objective and neutral; “distant”
• Some counselling approaches: supportive, non-directive, reflective
• CT:
  o Beckian: Collaborative empiricism, guided discovery, Socratic dialogue
  o Ellis: didactic, argued with client
• BT: Expert and coach

Question 3

Identify and describe considerations of the T-C relationship in CBT. (5)

Answer 3

• Establish a good relationship early in therapy
• Maintain relationship throughout therapy
• Attend to any problems (distrust, ruptures)
• Key features of CBT (collaboration, active participation, guided discovery) contribute to good alliance
• Here-and-now first (without inferring this is based on transference)

Question 4

How should resistance be analysed? (2)

Answer 4

• Analysed as a consequence of client beliefs about therapist or therapist’s actions
• If persistent/pattern of resistance, examine schemas
   Look for what their beliefs are

Question 5

Identify and describe relationship competencies required for the Beckian therapist. (3; 1; 3)

Answer 5

Collaborative empiricism
* Mutual agreement and discussion with regard to:
 Goals, how to achieve them, time frame and monitoring outcomes
 Formulation and ongoing changes to formulation
* Active involvement of client in therapy
* Guided discovery:
 Use of Socratic dialogue
 Learning experiments/experiences (Behavioural experiments, “homework”)

Question 6

What enhances the T-C alliance? (4)

Answer 6

• Collaborative empiricism
• Mutual agreement and discussion with regard to:
   Goals, how to achieve them, time frame and monitoring outcomes
   Formulation and ongoing changes to formulation
• Active involvement of client in therapy
• use of Guided discovery through socratic dialogue/learning experiments

Question 7

Outline the process of Socratic dialogue (4)

Answer 7

• 1) Asking informational questions
   Not just asking random questions, but questions that guide and direct
• 2) Empathic listening
• 3) Frequent summaries
   Helps client remember what they discussed
   Helps organise information
• 4) Asking synthesising questions

Question 8

What roles/duties does the therapist have in the T-C relationship? (7)

Answer 8

• o Shift roles based on needs of situation
• o Therapist roles
• o Shifts the lens/focus to particular areas of their life and get client to reflect that particular period of their life.
• o Reflective and insight-orientation to change beliefs and schemas
• o Skills training (coach) when required
• o Teach (expert) – data, research and facts
• o Supportive and validating of client’s emotions and experience

Question 9

Are there differences in T-C relationships across therapist orientations? (2)

Answer 9

o More pronounced in past; greater overlap now
o Greater in theory than practice (e.g., counselling uses exposure therapy, ALL use homework exercises)

Question 10

Are there differences in T-C relationships within CBT? (3)

Answer 10

o Most therapists are not purists
o Individual differences within CBT
o Beckian: greater emphasis on relationships than classical BT/RET

Question 11

What are some cultural considerations that need to be taken into account in the T-C relationship? (6)

Answer 11

• Awareness that own beliefs and perceptions are grounded in “dominant” or “own” culture
  o Diagnoses
  o Cause of illness
  o What is required to facilitate change
• Aware of blind spots
• Greater effort/time in engagement if different cultures
  o Show respect
  o Acknowledge difficulties
  o Be sensitive to race/minority status impacts
• CBT translates well to different belief systems
• Aware of different perceptions of pathology/helping/therapist
• Aware of language/translation difficulties

Question 12

What are some ethical considerations for T-C relationship in CBT? (1;4; 2; 1)

Answer 12

• Similar issues in CBT than other therapies
• Sexual relationships
  o Statistics (1% to 12%)
  o Power/consent – major issues
  o Extremely damaging to client
  o Severe penalties including loss of registration
• Other boundary violations
  o Dual relationships to be avoided as much as possible
  o Seek supervision if in doubt
• Extra care required during out-of-clinic outings for interventions (e.g., exposure therapy)

Question 13

Does psychoeducation differ from education? If so, in what ways?

Answer 13

• Psychoeducation is not just education
• Education
  o This component is a minor and relatively easy component of the psychoeducation intervention
  o Can be achieved by videotapes, handouts, internet, computer
  o Does not require a therapist
  o Focus is on **communication of accurate information **
• Psychoeducation is NOT education about psychological matters.
• Mental health professionals require education about psychoeducation!

Question 14

What is the CT perspective on psychoeducation? What is their perspective on receivers (i.e., the client)? (6)

Answer 14

• All receivers are biased processors – everyone, including therapists, are biased processors
• Information flow is dynamic - receivers actively shape the flow of information
  o They are not passive recipients (e.g., processing biases, “cognitive distortion” “thinking errors”
• Information may not be received in exactly the same way, even if the information is delivered in the same way to multiple individuals
  o Because individuals have different beliefs/processing biases
• Psychoeducation makes sure that clients receive information accurately, not really a focus on whether info is delivered by clinicians accurately

Question 15

What does psychoeducation focus on (1;2)? Why?

Answer 15

Focus is on
* Identification of barriers and resistance (beliefs and assumptions)
* Getting past barriers so information is received accurately
 Cognitive barriers
 Emotional barriers (I know it in my mind; but don’t know it in my heart/gut)

Why?
There are major barriers in receiving and interpreting information accurately

Question 16

What are the principles of psychoeducation? (11)

Answer 16

• Proceed from known to unknown
  o Use existing knowledge to integrate new information
• Deliver information in bite-sized chunks, not as in lectures
• Use verbal and visual information, adapt information to style of receiver
• If you sound like a tutor or lecturer, you’re doing it the wrong way
• Check out whether the client has understood the information
• Identify and work through barriers
• Check whether client finds the information credible now and when distressed
• Be aware of the “yes” response bias (attend to nonverbal content)
• Encourage discussion of misgivings, doubts, clarifications
• Pay attention to nonverbal cues
• Examine what the client believed about the problem, why the client held such assumptions and how this position has changed after the new information has been obtained

Question 17

What are some ways to overcome emotional barriers during psychoeducation? (10)

Answer 17

• Knowledge through experience is often more powerful, as it is mostly experiental
• Identify beliefs and assumptions that are cause of misappraisal or failure to grasp issues
• Use therapeutic interventions (not educational methods) to overcome maladaptive beliefs and assumptions
• Pace and absorption of information are slower.
• Repetition, consolidation and corroboration may be necessary
• Use analogies from disorders other than client’s to illustrate points
  o E.g., can use medical or eating disorder analogies – use whatever is more credible to client to help them relate and understand more
• Use behavioural experiments to test out aspects of the model if necessary
• Use homework tasks to corroborate, confirm, or consolidate message
• Get them to do ratings of beliefs – can compare from last week to this week
• The best psychoeducation is delivered in a two-way dialogue

Question 18

When considering a client’s beliefs about diagnosis, what should we examine? (4)

Answer 18

• What the diagnosis means to the client
• Has the client encountered someone else with a similar diagnosis?
  o Best case vs. worst case
• Does label have prognostic implications for client?
• Attitudes, assumptions and attributions
  o Ability to cope E.g., I just can’t cope with this now. This is the last straw
  o Beliefs about dangerousness E.g., Persons who are relieved/distressed they have panic attacks (vs. heart attacks) differ because they have differential beliefs regarding what is more/less dangerous
  o Dad/mum/god told me I would get this illness; they was right!

Question 19

When considering a client’s beliefs about psychopathology, what should we examine? (2)

Answer 19

• Clarify client’s pre-diagnostic conceptualisation - aetiology (cause) and maintenance
• E.g., I have a biochemical imbalance
• E.g., I am a professional/professor; it makes me angry when you say my thinking is distorted and dysfunctional
• E.g., I deserve this. I’ve done this to myself.
• E.g., I don’t deserve this. Why do bad things always happen to me?

Question 20

When considering a client’s beliefs about therapy, what are some common blocks? (7)

Answer 20

• Your solution does not fit my problem
• Size mismatch: “I’m not going to feel better by these simple strategies! “It’s too big to be fixed, period. I’m here just to hear you confirm that.”
• Causal mismatch: I don’t think psychotherapy, I have a biochemical problem
  o Linear vs. Circular causality
• Solution is too hard for me: “I don’t think I’ll be able to do this. I’m not that strong or motivated enough or capable enough for this solution.”
• Sequence mismatched: Cart before the horse: “Reduce my anxiety first, then I’ll do exposure therapy,” or “Get rid of my depression first, then I’ll do all of these activities you want me to do.”
• Solution is unfair:
  o Work/wicked witch put me in this hole! Why should I work so hard to become better
• I thought therapy was about someone else fixing my problems, but you seem to be saying that I’ve got to do all the hard work

Question 21

What are some other aspects (apart from psychoeducation) that we should prepare our clients for in CBT? (4)

Answer 21

• Active engagement in therapy - Unlike what client may expect
• Monitoring and evaluation
• Learning and discovery tasks (homework exercises)
• “Therapy” happens between sessions

Question 22

What is the CBT’s therapist approach? (4)

Answer 22

empathic, collaborative, flexible, patient

Question 23

Summarise:
CBT (3)
Psychoeducation (4)

Answer 23

CBT
* Relationship competencies are important but not sufficient to effect change
* Need scientific and skilled application of cognitive and behavioural principles
* Prepare clients before you deliver therapy

Psychoeducation
* Use best practice principles including but restricted to
* Clear dissemination of information
* Identification of barriers
* Ensure accurate reception/acceptance of information