Every psychotherapeutic process consists of two main protagonists: The therapist and the patient/s. There is often a misconception that this should be a hierarchical relationship, where the therapist’s command ought to be followed by the patient. However, this dynamic should in fact be one of equals, where both the therapist and the patient participate jointly in the decisions that are taken in therapy. Despite this, these decisions are often made unilaterally by the clinician, and they can result in the underuse or omission of several key therapy techniques.
In the case of Cognitive Behavioural Therapy (CBT), there are two main types of techniques – the ones in which you ‘talk’, and the ones in which you ‘do’. It has been observed that the most underused CBT techniques are the ‘doing’ (or behavioural) ones. For example, let’s imagine a patient with a phobia of heights. An effective approach with this patient would be exposure work – an ‘active’ technique in which the patient has to continuously face their feared situation (in this case, an elevated place) until the they feel more at ease and in control of their feelings. These behavioural components of CBT are challenging and stress-inducing, but interestingly, they are also the most effective.
Of course, exposure and other active techniques are intimidating and uncomfortable by nature, but not only for the patient – the therapist is also put in a situation where they have to deal with the patient’s distress. In order to avoid these difficult situations, clinicians might opt to omit these techniques under the belief that the patient is too fragile to endure them. But, what about the patient’s own opinion about these techniques? It is possible that the patient is willing to engage in them despite their difficult nature, and considers them important for their recovery. Then, the therapist would be delivering an incomplete therapy unjustifiably, making incorrect assumptions based on a perceived patient fragility.
Our study had the main goal of exploring how important are CBT techniques from the patients’ and clinicians’ perspectives. If both groups of participants gave similar levels of importance to the techniques, this could indicate that 1) therapists have informed the patients appropriately about the benefits of the techniques, and 2) clinicians have considered their patients’ preferences while planning therapy.
Our results showed that clinicians and patients differed in what techniques they considered more and less important. Specifically, clinicians considered not only the behavioural techniques more important than the patients, but also the talking-based ones. The only exception to this rule was ‘relaxation’, technique that was more valued by the patients than the clinicians. We also found that anxious therapists had a lower preference for ‘exposure’ and ‘behavioural experiments’ – both active, stress-inducing techniques. Even when our study did not show a tendency for clinicians to disregard specific therapy components, the discrepancies between both groups’ opinions are noteworthy.
Our results led us to the conclusion that communication between clinicians and patients is key, as well as the promotion of the techniques to the patients, so they are able to recognize the benefits of engaging in them. Without this openness, it is possible that the psychotherapeutic process fails, increasing the chances of patients dropping out, or finishing the treatment without reaching a significant improvement. We encourage therapists to discuss with their patients the best way of including their needs and preferences in therapy. Also, we encourage patients to be outspoken about these preferences, since their input is crucial for a
fruitful and successful therapy.
Read the full paper: Hernandez, M. E. H. & Waller, G. (in press). Are we on the same page? A comparison of patients’ and clinicians’ opinions about the importance of CBT techniques. Cognitive Behaviour Therapy. doi:10.1080/16506073.2020.1862292
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