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2. 关注来访的问题和优势

CHAPTER 2 Focus on Your Clients’ Problems and Strengths Let’s start with a check-in and review. In the last chapter we covered basic CBT theory, and we started using the four-factor model. Remember, the four-factor model involves exploring your client’s reaction to a situation by identifying thoughts, feelings, physical reactions, and behaviors. We also looked at how thoughts and behaviors can maintain problems. Did you try using the four-factor model? What did you notice when you differentiated thoughts from feelings? If you did not have a chance to use the four-factor model, try this exercise. Think of a situation in the past few days where you had a strong negative emotional reaction. Imagine yourself back in that situation. Now, try to identify your thoughts, feelings, physical reactions, and behavior. Afterwards, take a moment to reflect on the experience. Did you learn anything about yourself? Set the Agenda In this chapter, I want to focus on forming a good therapy relationship, understanding your clients’ presenting problems and strengths, and explaining CBT to your clients. Agenda Item #1: Develop a good therapeutic relationship. Agenda Item #2: Understand your client’s presenting problems. Agenda Item #3: Meet Suzanne. Agenda Item #4: Understand your client’s stressors and strengths. Agenda Item #5: Meet Raoul. Agenda Item #6: Understand your client’s psychosocial history. Agenda Item #7: Explain CBT.

Work the Agenda Shortly, I’ll introduce you to two clients, Suzanne and Raoul, whom we will work with throughout the book as we learn and practice CBT skills. But first, let’s start where all good therapy starts—with the therapeutic relationship. Agenda Item #1: Develop a Good Therapeutic Relationship For all types of therapy, including CBT, a good therapeutic relationship predicts a positive outcome (Martin, Garske, & Davis, 2000; Norcross & Wampold, 2011). Effective therapy happens in the context of a supportive relationship where your client feels understood and accepted. As with any form of therapy, when practicing CBT, it is important to be warm and nonjudgmental. You want to develop a collaborative relationship with your client, working together to solve her problems. You bring your knowledge about psychology and CBT, and your client brings her knowledge about her own life and experience. Multiple studies have demonstrated that empathy is a central component of any effective therapy (Norcross & Wampold, 2011). I would guess that you agree, but take a moment to think about how you define empathy. Usually, when I ask my students this question they answer, “walking in someone else’s shoes” or “understanding someone else’s feelings.” My students always mention feelings; almost no one mentions thoughts. Understanding feelings is important, but understanding thoughts is just as impor- tant (Elliott, Bohart, Watson, & Greenberg, 2011). Let’s consider an example. Sorena, your client, tells you that she feels sad and tired. She also tells you that she thinks she is an inadequate parent and that her children don’t respect or love her. If you wanted to be truly empathic, would you focus just on Sorena’s feelings or also on her thoughts? It seems to me that using the four-factor model and asking about both feelings and thoughts increases an empathic connection. Over the years, some therapists have told me that they think CBT is a cold type of therapy because we pay attention to thoughts. If you look at the previous example, what do you think? It seems to me that thoughts are as private and emotional as feelings. It is important to remember that when you ask clients what they “think,” you are asking them to reveal a very private part of themselves. In this book we will focus on how to be a warm, empathic therapist while also using structured CBT interventions (Josefowitz & Myran, 2005). Agenda Item #2: Understand Your Client’s Presenting Problems There is an order to CBT therapy. While there is some flexibility, typically the following order is implemented: •Explore your client’s presenting problem and obtain an overview of her current life situation, including difficulties and strengths. •Take a psychosocial history. •Explain CBT in general and in particular the four-factor model. •Set goals for therapy. •Focus on helping your client change. In the initial phase of therapy, you start to form a good relationship and at the same time get an overview of your client’s problems and how they are affecting her life. You also want to obtain a sense of your client’s strengths and how she has coped in the past. There are three main steps to obtaining an initial understanding of your client’s problems or why she came to therapy:

  1. Ask your client about her problems and make a list.
  2. Explore how your client’s problems are affecting her life and how she is coping.
  3. Collaboratively decide which problem(s) your client wants to start working on in therapy. Ask your client about her problems and make a list. CBT therapists usually start with “How can I help you?” or “Tell me, what brings you to therapy?” It is important for your client to explain her prob- lems in her own words. Initially, I focus on listening, using summary statements to be sure I have under- stood, and then ask open questions. Open questions encourage exploration and are not answered with just one word. For example, “Do you have a problem?” is a closed question. The answer is yes or no. “What kind of problem do you have?” is an open question. One way to think about this stage is that when your client starts therapy, the picture is blurry. Good questions help you gradually focus and sharpen the picture so that it is crisp and bright, or at least clearer. After you have a general sense of your client’s problems, it is helpful to make a list so that you can explore her problems more fully, one at a time. Writing out a list gives the message that therapy will address specific problems and not just be a place where she comes and talks in general terms. Making a list also starts to give direction to therapy. I usually say, “I am starting to have an idea of some of your concerns. I would like to make a list of your problems to be sure we have covered everything.” Most non-CBT therapists are not used to writing as part of therapy. Next time you have a new client, try writing out your client’s problems and share the list with your client. Pay attention to how making a written list affects therapy. Explore how your client’s problems are affecting her life and how she is coping. Often clients describe general problems, such as difficulty with their marriage or feeling anxious. To understand how a problem is affecting your client’s life, you need to explore further. You will find the following list of questions helpful. (You can download them in handout format at http://www.newharbinger.com/38501.) Questions to Explore Your Client’s Problems Question 1: What are some examples of situations where this problem arises? When you have this problem, what are your main thoughts, feelings, physical reactions, and behavior? I usually start with this question. Once you have examples of specific situations, the problem usually becomes much more defined. Question 2: What is the worst part of the problem? It is important to ask this question and not just assume that you know the answer. I am often surprised by my client’s answer. Question 3: How is this problem affecting your life? What are some of the difficulties this problem has created for you? In particular, are there activities you have stopped doing or are avoiding because of the problem? Are there activities you have started doing or are doing more of because of the problem? If my client is avoiding specific activities, I follow up by asking what she thinks would happen if she did not avoid them. Question 4: What have you done to try and cope with the problem? Have any of your coping methods helped? You want to know whether anything has helped, even a little, so that you can expand upon this coping strategy later. In addition, you want to acknowledge and support any active attempt to cope with the problem. Question 5: When did this problem start? Sometimes a client can immediately identify a triggering situation. Sometimes she has not thought about whether her difficulties were related to specific changes or events in her life. A series of relatively minor changes, over a short period of time, can equal a lot of stress. YOUR TURN! Practice in Your Imagination: Use One of the Five Questions I want you to imagine using the questions we just covered. Sports psychologists have known for years that imagining practicing a new skill significantly enhances skill development (Weinberg, 2008). It seems to me that if athletes can use imagery to practice, why not therapists? You can do the exercise by reading along, but I think you will find the exercise more meaningful if you listen to the guided audio file available at the website for this book. Look at Questions to Explore Your Client’s Problems. Choose a question which you rarely or never use. Now, choose a client with whom you want to try asking this question. Imagine your- self back in your office. Take a moment to look around; notice the sounds and smells of your office. Now imagine yourself asking this question with your client. Now, imagine asking this question with a different client. Each time, imagine that your client responds positively. Write down the question you choose, and try it with two clients this coming week.

Agenda Item #3: Meet Suzanne Throughout this book we are going to follow two clients, Suzanne and Raoul. They are based on a number of my clients and the clients of students I have supervised or taught. I want to start with intro- ducing you to Suzanne. We will meet Raoul later in the chapter. Suzanne is thirty-four and is married with two young children, Jennifer, age six, and Andrew, age four. She is a fourth-grade teacher and her husband works in a local hardware store. Her husband was her high-school sweetheart, and she is still in love with him. They live in the suburbs of a medium-size city. Her parents and her in-laws live nearby; she sees them regularly and they have a good relationship. Suzanne’s doctor referred her for therapy because she is always tired and feels chronically over- whelmed by the children, her job, and her other responsibilities. Her physical exam was normal, and her doctor thought it would be helpful for her to “talk to someone.” Suzanne calls the therapist’s office and makes an appointment. Suzanne is a small, thin woman who smiles timidly when she walks into her therapist’s office for the first time. She perches on the edge of the couch and looks nervously around. When Suzanne’s therapist asks, “How can I help you?” she responds softly with, “I’m not sure… I don’t know even know where to start,” and looks down. Her therapist gently asks, “Tell me what brings you here; I know it can be hard to start.” Suzanne explains she does not know what is wrong with her. She has a great house, great kids, a good job, and a great husband, but she is just so overwhelmed all the time that she isn’t enjoying life anymore. She starts to cry and says she feels like she isn’t coping. Her therapist asks Suzanne to tell her a bit more. Suzanne explains that she is always tired, cries over silly things, and quickly gets angry with the kids. She looks very sad and says, “I’m not even a good mother anymore.” Suzanne explains that she used to like her job as a fourth-grade teacher, but she dreads going into work these days. She is teaching at a new school, which is a thirty- to forty-minute commute. Her old school was walking distance from home. She is often angry with her husband. He works long hours and she feels she is expected to take care of the children and house without any appreciation from him. She is scared that he will leave her if she stays this depressed. She feels anxious all of the time. She has always been a shy person, but her anxiety is getting much worse; she worries over everything. Let’s see how we can start to understand Suzanne’s problems using Questions to Explore Your Client’s Problems. Therapist: Sounds like a lot. I think it would help if we made a list of your problems so we can start to understand them one at a time. Suzanne’s therapist’s response is both empathic and structured. Suzanne was feeling overwhelmed; her therapist thought that making a list might help her start to feel that her problems were more manageable. Suzanne lists being tired all of the time, yelling at her children, not doing anything fun, hating work, and wondering if teaching is the right job. These are all general problems, and we don’t really understand how they are affecting her life. Therapist: I think it would be helpful to understand a bit more about what is happening with you. Let’s pick one problem and look at it in more depth. Let’s start with exploring what is the worst part of this problem for you. (Question 2)

Note how Suzanne’s therapist explains what she wants to do by saying she wants “to understand a bit more about what is happening with you.” At the same time, she reinforces hope by saying “it would be helpful.” This is a good example of combining the structure of CBT with creating a good therapy relationship and instilling hope. Suzanne: I think the worst thing is that I’m always yelling at my kids and feeling like I am not coping. This is a very general statement. You want a more specific idea of Suzanne’s difficulties. Before looking at Suzanne’s therapist’s response, think about how you could ask Suzanne to identify specific situations that are difficult for her. Therapist:Could you give me some examples so I have a better idea of the situations that are difficult for you? (Question 1) Suzanne:Sure, I used to come home and make dinner for the family, and then play with my kids. These days just making dinner seems to take up all of my energy; I never seem to have time or energy to spend time with my children, and when I do, I am pretty irritated. As a CBT therapist, you are using the four-factor model to think about your clients’ problems. When Suzanne gave an example of a difficult situation, did she describe her thoughts, feelings, physical reaction, and behaviors? We have an idea of Suzanne’s feelings (overwhelmed and irritated/angry) and her physical reaction (tired); we don’t know her behavior or her thoughts. She mentioned earlier the thought I am not even a good mother anymore. You can guess that’s what she is thinking about herself in these situations, but it is important to check. Therapist: Suzanne, when you are feeling overwhelmed and irritated, what are some of the thoughts that are going through your mind? (Question 1) Notice that Suzanne’s therapist linked her thoughts to her feelings. Suzanne: I’m usually thinking that I am a terrible mother and the kids deserve better. But I am also thinking that I wish I could just go to bed and not have to take care of the kids. Try to think of an empathic comment that would summarize what Suzanne said and indicate that you had heard Suzanne’s thoughts. How could you ask Suzanne about her behavior and how she is coping? Think of how you would respond before checking what Suzanne’s therapist said. Therapist:Those sound like pretty difficult thoughts to be having. Lots of self-critical thoughts and then wishing you could just go to bed and get away from it all. Tell me, how do you cope in these situations? (Question 4) Suzanne:I just try to control my anger and take care of the kids. But I am pretty short with them. I have been trying to take it easy and go to bed early, to be less tired, but it hasn’t helped. Therapist:Have you tried anything that has helped? Suzanne: No, not really. How could you introduce Question 3? Therapist:I wonder if there are things you have stopped doing since you have been feeling so bad, or situations you are avoiding? Suzanne:Well, I generally do less fun things with my husband and children. Lately I am just too tired. This is a very general comment. How could you help Suzanne become more specific about what “fun things” she is doing less of? Therapist:When you say you do less fun things with your husband and children, can you give me some examples? Suzanne:I used to take my daughter, who is six, to a playgroup in the afternoon with some of my neighbors. I have a half day off from work each week. But I’ve been too tired to do that. Also my husband and I used to take the kids to the park on weekends, which was a fun family time; but I often send them over to my parents’ so that I can nap, or my husband takes them without me. When you look at Suzanne’s response, is there anything Suzanne has been doing more of? Suzanne’s thera- pist thought that she had been doing more resting and napping. This is a good place to ask about changes in alcohol consumption, drugs, and medication. Her therapist discovers that Suzanne has stopped doing most afterschool activities with her chil- dren as she is “too tired” and that she has also stopped seeing and talking with most of her girlfriends. She and her husband have also stopped seeing many of their friends and family because Suzanne feels that she is too tired. Suzanne’s problems started when she changed schools. She is unhappy at her new school, has made no friends, and feels like an outsider. Suzanne has not started consuming alcohol, nor did she report abusing prescription or nonprescription medication. Suzanne’s therapist suggested that they write down a preliminary list of the problems that Suzanne would like to work on in therapy. Suzanne suggested the following problems:

  1. Not having any friends at my new school
  2. Yelling at my children and husband
  3. Being tired all of the time
  4. Not doing fun things with my husband and children
  5. Being depressed and anxious and just not enjoying life anymore
  6. Wondering if teaching is the right job for me This is a long list; the therapist and Suzanne have to figure out where to start. Collaboratively decide which problem(s) your client wants to start working on in therapy. If you remember from earlier in the chapter, there are three main steps to obtaining an initial understanding of your client’s problems. First, ask about your client’s problems and make a list; second, explore how your client’s problems are affecting her life; and third, collaboratively decide which problem your client wants to start working on. We are now ready for the third step. Some clients come to therapy with one main problem, but most have a number of different prob- lems. You and your client need to decide which problem to address first, or therapy can feel like wander- ing around without a focus. The easiest approach is to be direct and say, “I think it’s helpful to try and address one problem at a time. When we look over your problem list, which problem would you like to start with?” You want to pick a problem where there is a good chance you can help your client fairly quickly and that will have an immediate impact on her life. Marsha Linehan (1993) suggested some very useful criteria for prioritizing your client’s problems. First, if your client is actively suicidal, your first priority is to make sure that she is safe. Second, if your client is behaving in a manner that is dangerous or that is likely to significantly interfere with her life, these behaviors need to be addressed. Examples of these types of behavior include major substance abuse, missing work or school, and being involved in a physically or emotionally abusive relationship. In addition, if a client regularly engages in behavior that interferes with therapy, for example, coming late to therapy, insulting the therapist, or skipping sessions, these behaviors need to be addressed. If we consider each of Suzanne’s problems, the first four that she listed are more specific and con- crete than being depressed and not enjoying life anymore or wondering whether teaching is the right job for her. The therapist explained to Suzanne that because the first four problems are more specific and concrete, she would want to start with one of these so she will be able to help Suzanne in a shorter period of time and with more focus to therapy. She then asked Suzanne which problem she wanted to start with. Suzanne wanted to start with making friends at her new school and not doing any fun things with her husband and children. Video 2.1: Meet John and Understand Your Client’s Presenting Problem Agenda Item #4: Understand Your Client’s Stressors and Strengths In addition to understanding your client’s presenting problems, you need to understand how these problems fit into her overall life. You want a picture of her current life, how she is functioning, and any other stressors or difficulties in her life besides her presenting problem, as well as the positive supports in her life and her areas of strengths. You can introduce this section by saying, “I am starting to get an understanding of your problems. I think it would be helpful if I could also get a sense of other parts of your life.” Notice that I explain what I will be doing and indicate that it will be helpful to my client. The basic categories that I ask about are family, friends and social contacts, recreation and involve- ment in organizations outside of the home, work or school, health, and finances. Finances includes the ability to budget, pay bills on time, and all that is involved in being financially responsible. When asking about health, if you did not already ask about alcohol and drug use, this is a good place to do so. I also ask about self-care, either under recreation or health. I want to know if my client is engaging in activities that are nurturing for her and if she is participating in any regular exercise. In addition, I ask whether over the past year or few years there have been any major changes in my client’s life, or a number of small changes. UNDERSTAND YOUR CLIENT’S STRESSORS Let’s start by seeing what we already know about Suzanne’s stressors or difficulties in each category. Suzanne’s Difficulties or Stressors Family • Often angry with children and husband • Believes she is no longer a good mother • Responsible for the children and home because husband works long hours • Frightened husband will leave her if she doesn’t change her mood and behavior Friends and Social Contacts• Unknown Recreation & Organizations• Unknown Work or School• Fourth-grade teacher who “dreads” work Health• Always tired • Otherwise unknown Finances• Unknown Changes• Started teaching at a new school that is a 30- to 40-minute commute from home • Can no longer walk to work every day and instead has to drive • Used to do fun things with girlfriends and participate in afterschool activities with children • Used to like her job When we use the table above, we can start to see areas where we need more information. Suzanne’s therapist continues to ask about her life. She learns that Suzanne has always been shy but has a small group of friends with whom she is close. However, recently she has been avoiding her friends, as she is just too tired to go out. Her husband is the main salary earner, and she feels guilty about asking him to help more in the home since she earns less than he does. She used to like work, but this year she changed schools. She has had trouble fitting into the new school; she feels different from the other teachers, who seem to form a tight group. In her previous school she was active in the school play, but she has been hesitant to volunteer for afterschool activities at her new school, where everyone seems to know each other. She reported that apart from lack of energy and being tired, her health was good and she had no problem with alcohol or drug use. She also indicated that generally, while they would like more money, finances were not a major problem. Between work and taking care of the children, she has no time for hobbies or recreation, though she enjoyed doing the school play last year. Suzanne indicated that she had not experienced any major stressors or changes other than her new job in the past few years. However, her mother-in-law, who used to babysit the children, had some health problems and was no longer able to help. Her daughter has had chronic ear infections. Suzanne often had to take time off from work to care for her daughter and take her to the doctor. Although her daughter is better, Suzanne is worried about the upcoming winter. Also, Suzanne’s best friend, Genia, moved away and she misses her. Suzanne was surprised at the amount of change in her life over the past few years and was able to see that all these changes together had caused a lot of stress. Let’s stop for a moment. At this point we have quite a bit of information. However, we forgot to notice strengths and areas of resilience. This often happens; as therapists, we are so used to thinking about our clients’ problems that we sometimes forget to think about their strengths. UNDERSTAND YOUR CLIENT’S STRENGTHS Before you can help your client see her strengths, first you need to see her strengths. It sounds easy, but it can be hard to see strengths. One way I use to recognize my client’s strengths is to remember that good things do not happen by magic. For example, a client of mine said her son “was lucky” because he was asked back for a full-time job after his internship. Stop for a moment—from what you know of the world, what needs to happen in order for a young man to be asked back for a full-time job after an internship? Does a fairy godmother just come and say, “Here is your job”? Her son had to get to work on time, work hard, do a good job, and probably be pleasant to work with. All of these characteristics are reflective of her son’s strengths. Now, he also had to be lucky, but luck is rarely enough. Here are some questions to help you think about your clients’ strengths based on the work by Christine Padesky and Kathleen Mooney (2012). You can download these questions in handout form (Questions to Explore Strengths) at http://www.newharbinger.com/38501. • Are there any areas of your client’s life that are going well, or any areas where your client has persevered in the face of difficulties or adversity? I do not mean just overcoming unusual chal- lenges, but also being able to maintain a routine. For example, Suzanne gets up on time every day, gets her children dressed, gets to work, and has dinner ready for her family. This takes thought, care, organization, and perseverance; it doesn’t just happen by magic. It is important to recognize strengths involved in accomplishing everyday activities. It can also be helpful to examine strategies people use to persevere in everyday activities. •Has your client been able to accomplish developmental tasks? For example, has your client been able to pass school grades, develop friendships, participate on sports teams, or have a steady job? These accomplishments suggest that your client was able to keep commitments, learn new informa- tion, and have positive relationships with other people. •Does your client have a responsible and caring relationship with either a person or an animal? Caring relationships involve commitment and putting aside one’s own needs. •Is your client acting according to her values or goals? Acting according to values and goals can be difficult and often involves putting aside what you immediately want to do in favor of long-term goals. •Is your client accomplished or competent in a specific area? People often have pockets of achieve- ments and skills. Being competent in a particular area does not have to be a huge achievement; it could be that you are the person who always makes the birthday cakes, or the person your friends turn to for computer help. Frequently the coping mechanisms that people have developed to succeed in these areas can be transferred to other areas of their lives. Let’s think about Suzanne and see how we would fill in the different categories for both her stress- ors and her strengths. You can download a Identify a Client’s Stressors and Strengths worksheet at http://www.newharbinger.com/38501. Suzanne’s Stressors and Strengths Family Difficulties or StressorsStrengths or Areas of Resilience • Often angry with children and husband• Stable, long-term marriage • Believes she’s no longer a good mother • Husband works long hours • Mainly responsible for children and home • Caring parent • Previously engaged in children’s activities • Maintains household routines • Provides stable home for family, last year able to care for sick child • Parents live nearby, good relationship • In-laws live nearby, good relationship • Shy Friends and Social Contacts • Currently avoiding friends• Small group of close, long-term friends Recreation & Organizations• Enjoyed organizing school play last year • No hobbies Work or School Difficulties or StressorsStrengths or Areas of Resilience • Dreading work• Grade four teacher (indicates completed undergraduate and graduate training) • New school, avoiding interaction with other teachers • Avoiding afterschool activities • Previously enjoyed work • Enjoyed colleagues at previous job • Participated in afterschool activities (school play) Health • Daughter has history of ear infections, not currently a problem • Own health is good • Does not use alcohol or drugs as coping mechanism • Daughter’s ear difficulties have resolved Finances Changes • Earns less than her husband and consequently feels guilty about asking for help• Earns a regular salary • Change in school• Despite all of the changes maintaining a stable home • Longer commute • Mother-in-law no longer babysits • Some health problems with her daughter • Genia, her best friend, moved away • Has a job with benefits • No particular financial stress • Responsible teacher • Organized babysitting • Recognized difficulties and coming for therapy Often in the beginning of therapy, clients are very hesitant to notice their strengths. In the next few chapters we’re going to talk more about how to use your clients’ strengths. Before we continue, ask yourself: how did thinking about Suzanne’s problems using the different categories affect your under- standing of her problems and strengths? What was it like to consciously notice her strengths?

Agenda Item #5: Meet Raoul It’s now time to meet the second client we will be following throughout the book, Raoul. Raoul is fifty-eight and lives with his wife in a medium-size city. He has three grown children who all live about an hour’s drive away. For the past twenty years he has worked at the same job as a govern- ment employee in the tax department. His daughter was home for a visit and noticed that he did not seem like himself. He told her that he was not sleeping well and was pretty anxious about work. She suggested that he see a therapist, and he reluctantly agreed. His daughter called and made an appoint- ment for him. Raoul introduced himself to his therapist with a formal handshake and gave his full name. He walked slowly into the room and lowered himself onto the couch with effort. He gave a small smile and said it was his daughter’s idea that he come. His therapist asked how she could help him. Raoul explained that in the past he has had periods when he felt depressed, but he was always able to get over them on his own. Lately he was depressed again, and things were not going well at work. To better understand Raoul’s concerns, his therapist used Questions to Explore Your Client’s Problems. Raoul said that his problems had started when a younger man was promoted to the job that should have been his. He explained in some detail how unfair the hiring process had been. Since then, he said, he has been having difficulty concentrating at work, and for the first time ever, he recently received a poor work evaluation. He is worried about the work evaluation and what the consequences would be if he receives another one. He stressed that for the past twenty years he has only received good year-end evaluations. Since the poor work evaluation there has been some tension with his boss. His therapist asked for examples of situations with his boss that were difficult, or projects where he was having difficulty con- centrating. Raoul had trouble giving specific examples of tension with his boss but was able to list the projects on which he was procrastinating. Raoul’s therapist asked about other aspects of his life, but he was very hesitant to talk about any- thing but his problems at work. Everything else was “fine.” He reported that he and his wife “have no problems.” He occasionally has a couple of beers when he goes out, but otherwise doesn’t drink. He said his health was good. He told his therapist that he was usually shy, but for the past five years he has been part of a bowling league, which his wife had encouraged him to join. His therapist assumed that as therapy progressed and Raoul learned to trust her, she would find out more about the other areas of his life. For the time being, she thought it would be helpful to focus on his work difficulties. Raoul and his therapist made the following list of problems he wanted to work on:

  1. Feeling anxious
  2. Not completing projects on time
  3. Sleeping poorly
  4. Tension with his boss

YOUR TURN! Raoul’s Stressors and Strengths Consider the information you already have about Raoul in relation to his stressors and strengths. Try to fill in the chart below. You can find my answers in the appendix. R aoul’s Stressors and Strengths Difficulties or Stressors Family Friends and Social Contacts Recreation & Organizations Work or School Health Finances Changes Strengths or Areas of Resilience

Exercise 2.1: Ruda Attends Playgroup Practice seeing a client’s stressors and strengths. Agenda Item #6: Understand Your Client’s Psychosocial History Most therapists take a history of the presenting problem as well as a general psychosocial history. Some therapists spend a whole session taking a detailed history; others ask for a quick thumbnail over- view. Even if you only take a brief history, it’s helpful to place your client’s current problems in the overall history of her life, being sure to also listen for her strengths and areas of resilience. Generally, when taking a history you are trying to figure out how your clients’ past experiences relate to their current problems. As a CBT therapist, I take a psychosocial history in a similar manner as any other therapist; however, there are two main areas that I emphasize and that might be slightly different from non-CBT therapists. First, therapists usually ask clients how they felt about a given event in their past; I make sure that I also ask what it meant to them, or what their thoughts were at the time. I am particularly interested in the messages my client learned about herself, others, and the future. Some of the questions I ask are: •How did you understand this event? •How did you explain this event to yourself? •What did this event mean about you? •What did this event mean about other people? •What did this event mean about your future? For example, a client of mine, Lisa, failed grade six when her parents divorced, and she went to live with her grandparents. When I asked if she thought that failing grade six meant anything about her, she replied, “I am not very smart, and without my parents’ help I couldn’t manage.” This is important information. Another client of mine, Michael, was sexually abused by his uncle over a period of three years, starting when he was eight years old. When I asked him how he understood the sexual abuse, he explained that he thought it happened because something was wrong with him and that he can’t trust anyone; he then added that bad things are always going to happen to him in the future. Early messages such as these will influence how your client feels, thinks, and behaves in her current life. The second area I emphasize is listening for strengths and evidence that my client is competent and lovable. I am starting to gather evidence that I can use later to counter any negative beliefs. Although it is not a hard-and-fast rule, I usually don’t share my perception of my client’s strengths this early in therapy. I have found that if I share my perception of strengths too early, it is just rejected. For example, my client Lisa, who failed a grade the year her parents divorced, mentioned that she passed the next year and completed nursing training. She was also one of the few students in her class to be offered a job immediately upon graduating. I kept that information in my back pocket, so that down the road when we start to explore her belief that she is not smart and can only manage with her parents’ help, I know that I have some evidence to counter that belief. Agenda Item #7: Explain CBT After you have an understanding of your client’s problems and have taken a history, it is time to explain how CBT works. Here is an example of how I might explain CBT. (A copy of Explain CBT to Your Client is available at http://www.newharbinger.com/38501.) I have heard a bit about your problems and how they are affecting your life. I want to tell you how I work. I use a CBT model. CBT is a goal-oriented form of therapy. I am going to ask you to set some goals for yourself in therapy and together we are going to focus on working toward them. Therapy will involve us first understanding your problems by identifying your thoughts, feelings, physical reactions, and behavior and how they fit together. We will then start to help you make some changes by focusing on one of these factors at a time. Since they are all related, a change in one factor will influence all of the other factors. At this point I often take a situation from my client’s life and together we explore her thoughts, feelings, physical reactions, and behavior. For example, in Raoul’s case we might pick his discomfort when he has to interact with his colleagues at work. You do not want to choose a situation in which your client has a very strong emotional reaction, as she will be too overwhelmed to listen to you and apply the four-factor model. After exploring a situation using the four-factor model, ask if this makes sense to your client. If you are working with children or teens, there are many wonderful games you can use to explain how thoughts can influence feelings, physical reactions, and behavior (see, for example, Kendall, Choudhury, Hudson, & Webb, 2002; Stallard, 2005). Video 2.2: Meet Charlotte and Explain CBT Homework: Practice CBT Before continuing with the next chapter, take some time to try the homework. Apply What You Learned to Clinical Examples Complete the following exercise. Exercise 2.1: Ruda Attends Playgroup Apply What You Learned to Your Own Life Try looking at your life in terms of your own stressors and strengths.

Homework Assignment #1 Explore Your Own Stressors and Strengths Use the table below to write down your stressors and strengths. Writing them down is important as it helps you step back and look at them. Did you learn anything about yourself? My Own Stressors and Strengths Difficulties or Stressors Family Friends and Social Contacts Recreation & Organizations Work or School Health Finances Changes Strengths or Areas of Resilience

Apply What You Learned to Your Therapy Practice For the next assignment, think of a client you will be seeing this coming week and identify a problem he or she is currently working on. Homework Assignment #2 Explore a Client’s Problem Look at the three questions below from Questions to Explore Your Client’s Problems. Complete the following table using the information you already have. What did you learn from this exercise? When you see your client, ask the necessary questions to fill in any missing information. Take a moment to reflect on what you learned from asking about the additional information. Client: Client’s Problem: Explore Your Client’s Problems Question How has the problem affected your client’s life? Is your client avoiding any situations because of the problem? How has your client coped with the problem? Client’s Response Was this a helpful question? If yes, how was it helpful?

Homework Assignment #3 Choose a Question to Explore a Client’s Problem Choose one of the three questions above that you have rarely or never used, and that you would like to practice using, or choose a different question from Questions to Explore Your Client’s Problems. This coming week, use the question you chose with two different clients. Be sure to notice each client’s response and the information you obtained. You can use the following table to record your experience. Question You Want to Practice: Client Client #1: Client #2: Client’s Response Was this a helpful question? If yes, how was it helpful? Homework Assignment #4 Identify a Client’s Difficulties and Strengths Choose a client you are currently working with and see if you can identify his or her stressors in the following areas: family, friends, recreation/organizations, work/school, health, finances, and any recent major changes or stress. Now look at Questions to Explore Strengths. See if you can identify any strengths and areas of resilience. Complete the table below. After you have completed the table, ask yourself how the exercise impacted your awareness of your client’s stressors and strengths. Identify a Client’s Stressors and Strengths Difficulties or Stressors Family Friends and Social Contacts Recreation & Organizations Work or School Health Finances Changes Strengths or Areas of Resilience

Let’s Review Answer the questions under the agenda items. Agenda Item #1: Develop a good therapeutic relationship. • How are your client’s thoughts important in developing an empathic relationship? Agenda Item #2: Understand your client’s presenting problems. • What are two questions that would be helpful in exploring your client’s presenting problems? Agenda Item #3: Meet Suzanne. Agenda Item #4: Understand your client’s stressors and strengths. •What are three categories you want to cover in exploring your client’s current life situation? •What are two questions that would be helpful in exploring your client’s strengths? Agenda Item #5: Meet Raoul. Agenda Item #6: Understand your client’s psychosocial history. • When taking a psychosocial history, what two areas might a CBT therapist emphasize that other therapists might not? Agenda Item #7: Explain CBT. • How could you explain CBT to your clients? What Was Important to You? What idea(s) or concept(s) would you like to remember? What idea(s) or skill(s) would you like to apply to your own life? What would you like to try this coming week with a client? (Choose a specific client.)

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