Psych Congress
Psych Congress
October 22, 2016
2 min read

Your cognitive behavioral therapy approach may need fine-tuning

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SAN ANTONIO — Clinicians learned how to develop effective treatment plans to overcome challenges presented by patients in psychiatric and mental health practices in a session here at the U.S. Psychiatric and Mental Health Congress.

“Often I’ll find when I’m supervising therapists that at the beginning of supervision they all use very broad terms to describe a difficulty that they’re having with a client,” Judith S. Beck, PhD, of the Beck Institute for Cognitive Therapy and Research, Bala Cynwyd, Pennsylvania, and the University of Pennsylvania, said. “They’ll say the patient is unmotivated or manipulative or aggressive. I don’t really know how to fix those things because those categories are too broad. We have to narrow down what do we actually see happening either in sessions or between sessions? And/or what is the patient saying or not saying in sessions or between sessions that’s a problem.”

Once the patient’s needs have been accurately defined, practical problems can be addressed.

Some practical problems include a patient not showing up for sessions or their interfering assumptions.

Beck recommended that clinicians rule out external factors to therapy, such as the patient cannot find child care and therefore misses a session.

Another practical problem cited by Beck was therapist error. To address therapist error, Beck recommended the following:

  • Establish a strong therapeutic alliance with the patient;
  • Set concrete, achievable goals that are within the patient’s control;
  • Ensure the patient agrees with the cognitive model;
  • Vary treatment based on the cognitive formulation of the disorder;
  • Ensure you have a valid concept of the patient and that treatment is based on a valid conceptualization;
  • Structure sessions appropriately;
  • Socialize the patient to therapy; and
  • Effectively implement treatment techniques.

Beck emphasized the importance of feeling safe in a session. She recommended the audience express interest in their patients and “act like a nice human being” in the room. This approach indirectly effects the patient’s core beliefs which brought them to therapy.

“It’s important to remember that patients are supposed to be difficult, especially patients with personality disorders – that’s why they're patients. You need to have that expectation before they enter your office,” Beck said. “You also need to have reasonable expectations for yourself. I’ve gotten better and better at it as I’ve gotten more experience and I have to say, I’ve learned from every patient that I see.” – by Amanda Oldt


Beck JS. Challenging issues in CBT: Handling the difficult patient. Presented at: U.S. Psychiatric and Mental Health Congress; Oct. 21-24, 2016; San Antonio.

Disclosure: Beck reports receiving editorial honoraria from Wolters Kluwer/Lippincott; book royalties from Guilford, Oxford University Press, Oxmoor House, Harper One; and scale royalties from Pearson.