Adapting Based on Client Attributes
Just as every client is unique, every therapeutic relationship is unique. Our challenge is to ensure that our CBT interventions are adapted to each of our clients’ particular strengths and abilities. With present-day knowledge and methods of investigation, we are limited to observational assessments of behavior during sessions. A client’s smile or yawn in response to our own smile or yawn may lead to a hypothesis about activation of mirror neurons, but we ultimately have to depend on our mapping of the client’s in-session behaviors to formulate a representation of his or her day-to-day interpersonal style.
Many of the CBT techniques involve clients in the process of identifying thoughts and emotions, which is influenced by the understanding of their own emotional experience and being able to detect emotions in other people. CBT therapists need to attend to and accurately read in-session displays of emotion, or avoidance of emotion and to understand the relational difficulties our clients describe in other areas of their lives (Klumpp, Fitzgerald, Angstadt, Post, & Phan, 2014; Mayer, Salovey, & Caruso, 2008; Samoilov & Goldfried, 2000; Siegle, Carter, & Thase, 2006). Thus, in a very real sense, we help our clients to develop their emotional intelligence (Hezel & McNally, 2014; Muris, Mayer, Vermeulen, & Hiemstra, 2007; Spek, Nyklicek, Cuipers, & Pop, 2008). CBT also involves an elaborative processing of the present moment, which demands a certain amount of executive functioning so that aspects of experience are monitored during an interaction, while consciously inhibiting unhelpful strategies from the past (Johnco, Wuthrich, & Rapee, 2014; Mohlman, 2013; Snyder, 2013).
CBT invites clients to attend to and sort out their thought processes, such as those that involve selective attention, memory biases, or other potentially dysfunctional ways to construct their experiences. Similarly, identifying and evaluating beliefs about thoughts, or thinking processes (i.e., meta-cognitions) requires certain aspects of intellectual functioning, such as receptive and expressive language, and abstract reasoning (Sasso
FIGURE 2.3. Summary of client attributes that require attention in the adaptation of CBT.
& Strunk, 2013; Waters, Mogg, & Bradley, 2012). Clients with low levels of intelligence, literacy challenges, fetal alcohol syndrome, attention-deficit/ hyperactivity disorder, psychosis, or a history of traumatic brain injury or significant alcohol and drug use, or who may be experiencing the onset of dementia, will require the therapist’s particular sensitivity and skill in providing CBT (see Figure 2.3).
Cognitive Case Conceptualization and Adapting Relationships
Although the competent practice of CBT depends on training and on the effective use of foundational counseling skills, these elements require skillful and sensitive adaptation for each client in each session. What may be experienced as empathic and supportive to one client could be interpreted as patronizing and demeaning by another. Every therapist’s behavior is viewed through each client’s set of values, beliefs, and assumptions. Hence, CBT therapists must walk a fine and constantly changing line, to ensure that their skills are appropriately adapted in a manner that is useful for their clients. In the next chapter, we discuss how the cognitive case conceptualization serves as a framework to adapt our generic therapeutic relationship skills for each client in each session.
‘To thine own self [and thine own clients] be true.