By David A. Clark, PhD
“Why do you want to see a therapist?” This question (or one like it) is often the opening remark of any Cognitive Behavior Therapist starting with a new client. It’s a recognition that people seek treatment for different reasons. Knowledge of these reasons becomes a cornerstone for building the cognitive case conceptualization. But there is another reason for wanting to explore the determinants of treatment seeking. People come to their first CBT session with a mindset filled with preconceived beliefs, experiences, and expectations about their psychological problem, its treatment, and CBT specifically. This mindset can make or break treatment success. By the end of the first session individuals are deciding on the extent of their commitment to the therapy process. Let’s consider two cognitive errors that can undermine a positive expectation for change.
The All-or-Nothing Error
Consider two opposing beliefs about CBT. Person A has heard great things about CBT and comes to the first session believing “This treatment is the answer for my distress. I should be depression- (or anxiety-) free once I’m done.” Person B has grave reservations about CBT and starts with the belief “CBT is just another form of talk therapy. How can this possibly be helpful?” You can see how both beliefs are problematic. Person A expects too much and so will soon be disappointed and Person B will quickly give up due to low expectations.
It’s important to address unhealthy beliefs in the first session. The therapist uses guided discovery to help the client take a more incremental perspective on therapeutic change. The therapist may say “Instead of thinking of change as all-or-nothing, let’s put it on a scale from 0 to 100, where 0 = zero percent change, 20 = 20% change, and so on up to 100 = absolute, complete change. What percentage of change would make therapy worthwhile to you?” Notice that this line of questioning is moving the client toward an incremental perspective on therapeutic change. Next the therapist can ask the client to list specific changes in thought, feeling or behavior that would indicate the desired level of change has been achieved. If working in a CT-R perspective, these indicators could be linked to the client’s values, goals, and aspirations. This work on treatment expectations can be included in the case conceptualization and goal setting.
The Overgeneralization Error
You begin the first session and quickly learn your client has past experiences with psychotherapy and possibly CBT in particular. Even if a client is new to CBT, information on the treatment is widely available online and in social media. This can bias individual’s expectations for current treatment. An individual may erroneously generalize from a negative or disappointing experience with a past Cognitive Behavior Therapist to your therapy approach. For example, a client concludes “My previous Cognitive Behavior Therapist(s) didn’t really understand my situation because they said the problem was my thoughts. I expect the same will happen with this new therapist.” It is easy to see how this erroneous belief would hamper efforts to establish rapport in the first session.
Again, Socratic questioning and guided discovery can be helpful in this context. The therapist can ask the client to think back to various teachers, instructors, or consultants they had over their lifetime. “Were all teachers the same? Did they find some teachers more helpful than others? Were they able to connect better with some teachers than with others?” The client could be asked to report on a couple of characteristics they liked about a particular teacher. This discussion could conclude by noting that therapists are a lot like teachers. Most people find they can connect with some therapists better than others. The therapist invites the client to see how well they’re able to connect over the next couple of sessions. The client is encouraged to report when anything is said or done during therapy that they feel disrupts their connection with the therapist.
The first session sets the tone for the rest of the therapy experience. The mindset that individuals bring to their first session will facilitate or hinder client commitment to the therapeutic process. To nurture hope and build a positive expectation for change, the therapist must address any pre-existing unhealthy beliefs and biases that clients bring to their first CBT session.