Cognitive-Behavioral Therapy: Theory, Techniques, and Applications, 3rd Edition _ _____________________
Clients may also present with questionable treatment adher- ence. This may occur when a client does not complete their homework or frequently misses sessions, but also when the cli- ent is overly adherent to assignments (e.g., the client completes homework and takes assignments further than warranted or instructed; Ledley et al., 2020). There are several potential reasons for such behavior, and such issues are often discussed with the client. Exploring potential barriers to treatment adherence will not only assist the therapist in addressing this matter. Still, it may also provide information that assists the client in a further understanding distorted thought patterns. For example, the client may “forget” to come to a session. Exploring this behavior may further reveal that the client did not complete their homework because of a belief that they will be rejected or admonished by the therapist because of not having done the homework perfectly. This could reflect a dysfunctional intermediate belief of “If I make mistakes, then people will reject me,” and the client’s behavior may thus reflect avoid- ance. In either case (under- and over-compliant clients), the therapist can explore the client’s beliefs and assumptions about therapy, change, and their ability to succeed in therapy. If distorted thoughts or beliefs affect a client’s behavior in these cases, an evaluation of such cognitions can be brought into therapy to illustrate how maladaptive thoughts can lead to (or maintain) maladaptive behaviors. Adherence issues can reflect such cognitions but can also signify that the homework is too complex, simple, burdensome, time-consuming, or painful. Perhaps the schedule of appointments is not well suited to the client’s schedule or responsibilities. Adherence issues could also indicate that therapy is not targeting the most salient thoughts or beliefs. The therapist must also consider the client’s environment, intellectual ability, and other factors affecting the client’s efforts to change. Some clients present as quite talkative during sessions, but perhaps not about the topic for therapy. Or maybe the client does not adhere to the agenda and seems to have difficulties staying “on track.” Ledley and colleagues (2020) suggest mul- tiple potential reasons to consider should this occur. Perhaps the client does not understand the structure and function of cognitive therapy; if so, the therapist can review such matters further with the client. Or perhaps there is a misunderstand- ing, and the client believes that therapy is a place to “vent.” In such a case, the therapist can revisit the nature and process of cognitive therapy. Perhaps the client thinks the therapist needs to know “everything” to “truly” understand them. In this case, the therapist can provide additional education and even engage the client in evaluating the rationality of this belief, thereby beginning to model the process of cognitive therapy. Alternatively, perhaps the client is nervous, does not know what they are supposed to say, and therefore talks about whatever happened that day. It could even represent cogni-
tive avoidance; by discussing off-topic issues, the client may be attempting to avoid discussing more relevant themes and concerns. The therapist can try to uncover the reasons for the client’s talkative approach to therapy directly. The therapist must also consider the client’s underlying core beliefs, previ- ous experience in therapy, understanding of the therapeutic process, and expectations for therapy. Acknowledgment of fears and concerns and education regarding structure and process may be quite helpful. It is not uncommon for clients to terminate therapy early. For example, the client may not return for therapy following the assessment or not show up for sessions shortly after therapy begins. Reasons for this could be as straightforward as dif- ficulties with scheduling but may reflect other issues as well. Perhaps the client was pressured into attending therapy by a family member or was mandated to participate by the court; such factors will provide clues about the client motivation. The client may believe therapy will be painful and avoid the experi- ence. The client may believe that therapy will not help them. Also, the client and therapist may not have been a good match, and the client cannot articulate or feel comfortable asserting their needs. There are a tremendous number of reasons this may occur. During the initial sessions, the therapist can take steps to ensure that the client is well-educated about cognitive therapy, has realistic expectations, and is encouraged to voice concerns (including concerns related to the relationship and comfort with the treating provider). Discussing thoughts and beliefs about therapy, how therapy works, and what outcomes are anticipated can also be helpful. The therapist’s own beliefs and assumptions can also impact therapy (Freeman et al., 2004; J. S. Beck & Beck, 2011). For example, therapists might feel unsure how to help the patient. Therapists may experience strong negative reactions to some patients or may be engaged in their own cognitive distortions about their abilities or about the clients. The therapist may share some of the client’s beliefs and assumptions and, there- fore be challenged in recognizing the dysfunctional aspects of the client’s cognitive patterns. To address such matters, the therapist can take steps to be aware of their dysfunctional beliefs and reactions to clients and address the situation as needed. Sometimes, the therapist may opt to examine their own thought patterns, consult with a supervisor, solicit consul- tation from a qualified peer, and possibly even refer the client to a different provider. When problems arise, and they surely will, the therapist might consider taking a look at each of the following to help identify the nature of the issue at hand: • Diagnosis • Conceptualization • Treatment plan • Therapeutic alliance
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