Keys to Effective CBT: Holding Patients Accountable While Building Warmth and Connection

Jill Levitt, Ph.D. and Mike Christensen, MACP, RCC present the online workshop, Keys to Effective CBT: Holding Patients Accountable While Building Warmth and Connection at Feeling Good Institute.

In the video, Jill Levitt, Ph.D. and Mike Christensen, MACP, RCC express gratitude for the participants attending a live online workshop at Feeling Good Institute, focusing on accountability in therapy on the patients' and therapists' part . They acknowledge the topic may not be as exciting as quick solutions to specific issues but emphasize the importance of consistent therapy practices.

The presenters introduce the Team-CBT framework developed by Dr. David Burns, which emphasizes measurement, empathy, and addressing resistance. They discuss the significance of setting clear CBT goals and expectations with patients early on, using metaphors such as comparing therapy to personal training for the mind or learning to play an instrument. The presenters stress the need for therapists to communicate what they can offer, outline the patient's responsibilities, and ask for the patient's commitment to the process.

They share examples of tools, homework, and measures they use to track progress. The presenters also highlight the importance of being flexible and empathetic while holding someone accountable, empowering them to make choices regarding their therapy journey. The video aims to prepare participants for interactive exercises and discussions about implementing these concepts in therapy sessions.

IN THIS VIDEO: 

Jill: Welcome everyone to our new workshop today. The keys to effective CBT: holding patients accountable while building warmth and connection. I'll be presenting today alongside my dear friend and colleague, Mike Christensen. I wanted to say a few things on this slide. First, for those of you who are wondering why David is not here, it's because he's currently busy with his app. However, he'll be back teaching with us again in February and working on lots of projects. So, I want to assure everyone that David is doing great.

I'm also super excited about the opportunity to teach with Mike. If you don't already know Mike, you will find today that he is a fantastic clinician, a warm human being, and an extremely clear and helpful teacher. I'm really excited to be teaching a lot of David's material with Mike today.

We have a few introductory slides, and then we'll get into the heart of it today. The mission here at Feeling Good Institute is to alleviate suffering by nurturing elite therapists. Our goal is to help patients by training and supporting therapists in doing high-quality CBT. We started back in 2013, mentored by Dr. David Burns at Stanford University. We work hard to train and certify therapists in the processes of effective therapy. We'll talk more about them on an upcoming slide, but we focus on measurement, empathy, increasing motivation, reducing resistance, and the methods of cognitive-behavioral therapy.

All of our therapists are highly skilled and vetted therapists and trainers. We focus on weekly training, where all of our therapists get together and consult on cases and use deliberate practice to improve our skills week over week. We offer video-based therapy across the US and Canada, as well as in-person treatment centers in New York, Silicon Valley, Canada, and Israel. We offer outpatient therapy, intensive therapy, where people fly in or drive in from out of town to visit us and engage in many hours of therapy per day, many days a week, in order to get over their suffering faster and more efficiently. We also offer online options.

I won't go through all the people on this slide, but this is our leadership team. I also want to say thank you today. The way that Mike and I are teaching, we'll be doing a lot of didactic teaching, demonstrations, and polls to engage you. However, our favorite way of teaching and your best way of learning is practicing. We wouldn't be able to practice without our helpers and small group leaders. You'll be sent into practice groups two different times throughout the day today, and you'll have leaders that will facilitate your practice of the skills you're learning.

I also want to say a big thank you to LJ Davis, who is our director of online experience. He's taking care of everything behind the scenes so that Mike and I can focus on teaching. Thank you, LJ. Richard Lam is here with us, helping with tech support. If you have issues with accessing the slides, Zoom, or Talent LMS, you can send a chat in the chat box to Richard, and he'll be there to help you. Daniel Hermann will be behind the scenes assigning you to breakout groups. If you drop off and suddenly are no longer in your group, you'll land back in the main room, and Daniel will make sure you get to where you need to go throughout the day.

We will also be fielding questions from you. If you have questions, please send them in your chat box to Todd Daly. Todd will be relaying your questions to us. Zane will be helping us with your participation. When we ask for your input, you can type your answer to Zane. All these people are here to make this workshop much more interactive so that we can connect with you and not just talk at you.

LJ Davis: Richard is not here yet, so if people have tech questions, they can chat with me instead.

Jill: Thank you, LJ. Richard may be responding to people via email and trying to assist them. We are recording the workshop today so that we can make it available to those who registered, whether or not they are with us. The recording will be put on the workshop page. If you don't want to be seen in the video, you can choose not to speak up in the large group or enable your video. We won't be recording your breakout groups.

Lastly, I want to say this and I'll say it again later again at the end of the day, but the majority of you are here. So, in order to get your continuing education credit, you need to be present for the whole day. That means you signed in with your attendance on the workshop page, which you saw before the zoom link. You're here the whole day, you're in your breakout groups, you're here till the end. At the end, we'll put the link to complete the CE survey in the chat box. It will make it really easy for you. You don't have to log back in to the workshop page. So, we'll put the link in the chat box, and you'll click that link and fill out your CE survey right at the end of the day, 5:01 PM. Then, you'll be emailed your CE certificate. We can't accept late submissions, so if you text me or email me a week from now saying that you were here but didn't fill out the survey, unfortunately, we won't be able to give you CE credit. So, please make sure you fill out the CE survey right at the end of the workshop today so that you can get credit. I won't go into too much detail here.

This is really just to give you a sense. We'll be taking a break around 10:50 AM. We'll be teaching, demonstrating, and you'll have opportunities for breakout practice and giving us feedback throughout the day. At the end of the day, we'll also have some time for Q&A and wrap up. These are approximate times, and we'll do our best to stay on track.

Let's shift gears now that we got all of that stuff out of the way and get into the heart of what we're going to be teaching today.

First, I want to say cheers to all of you for showing up and wanting to learn about holding yourself and your patients accountable. This is not the sexiest topic. It's not about how to cure trichotillomania in five minutes or how to overcome social anxiety in two hours. This is really about the relentless act of keeping your patients on track in therapy and holding yourself accountable to doing really effective therapy. I appreciate that those of you who are here are really wanting to learn and work hard.

Today, we'll be talking about dealing with resistance, but I want to briefly teach you about the framework we're coming from. Mike and I do what's called team therapy, a framework for doing therapy developed by David Burns. It's based on what we know to be most effective in the processes of therapy. We use testing or measurement at all of our sessions with all of our patients to track their symptoms, make sure they're actually getting better, and course correct if they're not.

We also check in with them at the end of the session to see how it went for them and address empathy failures or ruptures throughout therapy. We also teach, train, and use empathy, which means we connect with all of our patients, not just rushing in and trying to change them. We spend time at the beginning and throughout our sessions connecting with our patients.

The third bullet here is the "A," which stands for assessment of resistance. It's more than just assessing; it's really addressing resistance and thinking through with our patients what are good reasons not to change and what are the values of the symptoms they have. Specifically today, we'll be evaluating if patients are willing to do the work they need to do in order to change and why or why not. We bring resistance to conscious awareness so that we can help our patients melt it away and engage in the methods of therapy more effectively. Today, we'll be focusing a lot on accountability, which is a variation or nuance of resistance. I'll turn it over to Mike here.

Mike: Whenever I attend a workshop or a course, my hope is that I'll be able to learn something so that I can improve or grow and it'll address some challenge that I'm having. So today, we want you to think about what challenge we're hoping to address. I'm going to launch a poll and ask yourself the question: Do you have patients or clients who don't do their homework, show up late or miss sessions, are hesitant to fill out measures, or reluctant to get to work in sessions?

Check all that apply. I'll give you just 15-20 seconds to fill that out. Alright, it looks like we already have 95% of the people. I'm just going to close the poll. This is very affirming and a bit of a relief for me because I've certainly had all of these, and it seems like the majority of you have had a lot of them as well. 95% have had patients or clients who don't do their homework, 57% show up late, 56% are hesitant to fill out measures, and 68% are reluctant to get to work. We're hoping to address each of these in some measure today.

So, we ask ourselves, why should we hold our patients accountable? What would be the purpose of holding our patients accountable? Jill, if you can go to the next slide.

The first thing is we know it leads to better outcomes if patients are aware of what they need to do and actually do it, then the outcomes are better. It also really builds trust, um, with clear expectations.

It's a respectful way of delivering therapy, which leads to less frustration for the patient and less burnout for therapists when you're stuck with patients. I know for me it's with the ones that I get a little bit where am I going, that seems like we're in the mud here. It can be draining and exhausting.

The third thing is it's very empowering for the patient. It's giving them a sense that you believe in them when we set these clear expectations and that we hold them accountable.

And then finally, it protects patients from disappointment. We don't want to set them up with the expectation we can deliver something that we can't if we're not holding them accountable. So, um, the last thing I want to do is be the next therapist that didn't work for them. I want to be the one that sets them up for success.

And so, it's a few keys that we lean on in order to address these. The first is we want to start early with setting expectations. We're going to do a little bit of practice with that even in our consultation, the 15-minute, we call it our 15-minute phone or I do video consultation. I start then. We want to provide a sense of hope. You're not just saying I'm demanding and here's what you have to do, but you want to give some opportunity for them to think about what the process will be like and what the outcome will be like and what you have to offer them. And be clear about what we have to offer them. I want to be clear about what we expect from them. You're going to be working together as a team, so you're really setting the ground rules.

And at the same time, and I think this one is important, we want to be flexible in the sense of knowing what the patient's capacity is. You're not going to set them up with something that they can't actually do. I worked with a client at one time who had a brain injury due to a car accident, and while I require people to fill out a mood survey before and after every session, in the vast majority, I send it to them ahead of time or give it to them before they come into the office. This person had a difficult time kind of reading and comprehending. That was part of the challenge. So, I had to be a bit flexible on how we delivered that form. So, we want to keep in mind what the patient's capacity is and set those expectations based on what they can handle.

And then finally, we want to make sure we're asking for commitment while giving the patient full agency to choose whether or not they're going to engage in the process. We want to give them permission to say no but not feel bad about it, to feel actually good about saying yes or no in regards to what we're going to have them offer. Jill, anything you wanted to kind of add or clarify there?

Jill: Yeah, no only, well just about the keeping in mind the patient's capacity. You'll see today, as Mike said, that we're very much trying to hold our patients accountable and hold ourselves accountable. And so, you'll be practicing and we'll be demonstrating for you how you kind of say, you know, these are the things that you'll need to do in order to recover, and these things are kind of non-negotiable. That's the way we think about it. But I think this second-to-last bullet here is really important. I told Mike, Mike and I met on Sunday to sort of finalize our slides, and I said, you know, I actually attended a workshop on Saturday where I was learning about neurodiversity in CB, and one of the things that I was learning about was being flexible, right? That certain patients, for example, I use exposure therapy with pretty much all of my patients who struggle with anxiety. And yet, some patients with autism will need to approach anxious situations differently. Exposure therapy could actually be overwhelming and flooding for them in a way that's different for a neurotypical patient. And so, our point here was really just to share with those of you who are worried that we're rigid and inflexible that while we are very much wanting to hold our patients accountable, we also realize that patients are individuals, and we do want to pay attention to what they can and can't actually do. So, I think that was it.

Mike: Yeah, appreciate that, Jill. One of the first obstacles that we want to address is that patients don't realize what it will take to get better. Often times, patients or clients will come into therapy with an expectation, and they may have kind of this Hollywood idea. They've watched a movie and suddenly somebody just talked and had this great realization and didn't see any of the work that the clients are doing in between. So, we want to be really clear about what it's going to take to get better. And I set this up very early, even in my 15-minute consultation, which is primarily about connecting and getting a bit of a sense of what they're hoping for. But before I wrap up the consultation, I let them know how I work. You know, I say I'm kind of demanding.

I remember having this gentleman call me, and he started off by saying, "Oh, I'm so excited to meet you. I know you're the therapist for me." And that felt kind of nice. He'd listened to some podcasts and some things that I'd done with David. And as we began to talk and he told me a bit of his background story, and one of the questions I ask is, you know, have you seen other therapists before? Have you done any counseling before? I want to get a sense of what did work for them, if they did some work or what didn't work, and he said, "Oh, I've seen numerous counselors and a number of psychiatrists, and I've actually been kicked out of a couple of treatment centers. You know, I have this diagnosis, but I know you're the guy for me." I thought, "Oh, no pressure, no pressure, right?" And I thought, "Huh, I want to be really clear with this gentleman. I really liked him, and I thought it would be really kind of fun to work with him because we seem to be connecting very well. But at the same time, I was a bit nervous that there are probably some pretty remarkable people who worked with him over the years that could not deliver for him. I didn't want to set him up with an expectation I could deliver something that I couldn't." So I said to him, "You know, my sense is that you've been a little bit set up in the past, and people haven't been entirely with you and maybe couldn't deliver what they promised, and that wouldn't be fair to you. So I don't want to do that. I'm actually going to be pretty demanding right now and tell you what it will require before we would start working together." I said, "Because he talked about a lot of hopelessness and some other dynamics, I want you to do is you told me you've already bought the book 'Feeling Great,' and I want you to read it completely and do all the exercises in it. I'm also going to send you something called the anti-hopelessness memo, which is a 22-page kind of homework assignment, and I want you to complete it in its entirety with all the exercises done. Once you have that done, then contact me, and we'll look at where you might be stuck, and I can help you.

Now, one of the drawbacks of this approach is if you do all this work, you may recover and not need to see me because you may discover that you find the tools you needed. I'd love to work with you. I think it would be great. But until you do that, I don't know how to help you without that done. Now, that can seem pretty extreme, pretty demanding, but his response to me was, "Thank you so much for being honest with me and being real and believing in me." Now, I imagine some of you thinking, "Now I'm going to tell a story about how he did the work, and then we came back and did this great work together, and he had this recovery in two or three sessions." But the truth of the matter is I never heard from him again, and to me, that's actually successful therapy because I didn't become the next therapist that disappointed him. Whether he did the work and succeeded in it and got the recovery he needed, he may have, and that would be wonderful, that would be great. But if he didn't, at the very least, I didn't contribute to his hopelessness by setting him up with something that I couldn't deliver. So we want to be really clear about what it takes, and I start in the 15-minute consultation.

Jill: I love that story, Mike, and I also love Mike and I talked about how oftentimes we share success stories, and we feel like it's really important throughout the day today for you to realize that it's actually a success if a patient realizes that they don't want to do the work and don't want to be in therapy because it's a success from the perspective of the alternative would have been some sort of watered-down, diluted, push-pull resistant therapist burnout therapy, right? So we want to help patients to be really engaged and making progress in therapy, or we want to give them permission to say, "It's not the right time for me," or "I don't want to do the work," and to feel actually okay about that, right? So it's ultimately, we feel like holding patients accountable and holding ourselves accountable is just like the deepest form of empathy and respect that we can really offer our patients.

So let's walk you through the first piece we're going to be teaching and demonstrating and practicing today is how to set expectations early. We say within the 15-minute consultation, just to be clear, if you don't work that way, I mean, what the way that we work is usually if a patient is interested in working with us, we'll speak with them over the phone or by video to hear a little bit about what they're wanting help with and to share with them about the way that we work so we can figure out whether it's going to feel like a good fit. If for some reason you don't do that and you just meet with people right off the bat to do an evaluation, this can be a part of that session as well, right? It's just about making sure that you're not just starting right off the bat with the patient, but in addition to assessing and connecting, that you're being clear about what you have to offer and about what it's going to take from them in order to get better.

So to that end, basically, we say after gathering information, whether that's on the phone or video and empathizing with them and connecting with them, you're going to sort of do these three things, and that's what we're going to talk about this morning. You're going to state what you have to offer, and I'm going to walk you through that in the next few slides. That's sharing with them that you have the tools to help them, that you'd love to help them get better, and that's kind of the good news. We call that dangling the carrot. You're also going to clarify what it's going to take from them because we're not magicians, and we can't just fix people without their cooperation and participation, so we're going to tell them what it's going to take from them.

We call that, at some point throughout the day, the gentle ultimatum. What are you going to need to do in order to get better? Then we're going to ask them what they think of that. Are they willing to do that? We're going to ask them in a way where it's clear that they can say yes or no. That's what we're sitting with: Open Hands. Are they going to be willing to do that work? I would really understand and respect them if they chose not to. That's the kind of sitting with open hands.

Let me tell you a little bit more about the Carrot. We can Dangle the Carrot in multiple ways, and we'll be teaching you this related to different parts of the therapy session. One thing we can do is say that we have lots of great tools that we think will help them. We're experienced in what they're looking for help with, whether it's social anxiety, panic disorder, or depression. We can say we have lots of great tools that we really think can help them overcome their depression or anxiety. We can also share with them that we love helping people who struggle with social anxiety or depression. We'd love to work with them, as Mike said. We think we do really great work together. We can also imagine the great outcome they might have if they did this work. It'd be incredible to see them feeling confident and building connections again, feeling joy and happiness. We've seen that happen for so many others. We'd be really excited to see that happen for them. We want to share with them what we have to offer in a positive and optimistic way.

Mike: Clarifying what it will take is what we call the gentle ultimatum. I love this term because gentle is key, but ultimatum is also key. Sometimes we can lean one way or the other. In order to deliver a gentle ultimatum, you need to first know what you're going to require. What are the key elements to bring about the recovery they're looking for? They're going to have to do it. The gentle part is delivering that in a way that's open, warm, and inviting. You can say something like, "I've got to be honest with you. I'm pretty demanding, but it's because I believe in people. I want to be clear about what I'm going to ask you to do so you know what you'll be signing up for with this approach." That's going to take a few things.

Examples of requirements might be 20 minutes of homework a day, five days a week for someone with depression, where they write out their negative thoughts and challenge them. It could be completing measures before and after every session. I don't do any sessions without some form of mood survey before and after. I feel like my son is a car mechanic, and if you ask me to do therapy, it's like asking my son not to use his tools to fix your car. He'd say, "I'm sorry, you can go to the next garage, but I can't do that." I'm the same. It's a key tool for me. Then, weekly sessions, committing to actually engaging in the work and setting aside time in their schedule to engage fully in the therapy.

Jill: After we've shared with them what we have to offer and what it would take, we're going to ask them for commitment. Otherwise, all we're doing is kind of talking at them. We're going to say, "I want to check in with you. Are you willing to commit to this process? It's not for everyone, so I want to make sure that it feels like a good fit for you." That actually feels very comfortable to me because I tell people that the 15-minute phone consultation is an opportunity to figure out whether we're going to be a good fit for each other. After I listen to them and say, "I think I could help you with what you have to offer," I'm kind of saying, "I think I'm a good fit for you." Then I'm saying, "Are you a good fit for me? Do you want what I have to offer?" We could say, "Not everyone chooses to work with me, and I totally respect that. This might not be the approach you're looking for. I'd love to work with you. Is this something that you'd be willing to commit to?" Go ahead, were you going to say something?

Mike: Metaphors can be helpful to bring it to life for people. One of the ones I use even in the 15-minute consult is to say, "I'm kind of like a music teacher. I took piano lessons growing up, and my mom was always saying, 'Practice, practice, practice.' When you come to therapy, I could play some music for you and show you some books about piano, and even model some things for you. But unless you're practicing in between our lessons, you won't learn how to play the piano. You won't learn how to overcome this depression and be able to play the music of life, of joy and self-esteem. It's going to take that 15 minutes of practice, that we call homework, every day."

Jill: Then, the metaphor that I often use with patients is to say, "I'm kind of like a personal trainer. I frequently say it over during my 15-minute phone consultation, I don't always use these metaphors. It depends on how invested the patient is from the beginning. If the patient already knows about therapy because a friend went to see me, I don't have to explain as much. However, if the patient seems enthusiastic and eager for me to "fix" them, I take a more thoughtful approach. I often tell these patients that doing therapy homework is an essential part of getting better.

I compare therapy to personal training for the mind. If you hired a personal trainer who met with you for one hour once a week and gave you a great workout, but you did nothing between sessions, would you get stronger? Patients usually laugh and say no. I explain that therapy works the same way. We can have a great session for one hour once a week, but if you're not putting in the work between sessions, implementing the skills and practicing, you won't overcome your depression or anxiety. If you're willing to put in the time and apply what we do in sessions to your life outside of therapy, then I would be a great fit for you. If that doesn't sound appealing, I understand. This personal training metaphor resonates with people, and I also encourage patients to develop their own metaphors. Learning from other therapists about how they describe concepts to their patients can be helpful too.

For example, David often uses the metaphor of learning how to play tennis or basketball to explain the importance of using measures in therapy. Basketball players improve their shots by taking a lot of shots and getting instant feedback. If therapists don't use measures, it's like shooting without being able to see if the ball goes in or not. Using measures throughout therapy is crucial.

Now, let's pause and see if anyone has questions about what we've presented so far. If you have any questions, please enter them in the chat box for Todd to relay to us. Todd, can you unmute yourself and let us know if there are any questions?

— Q & A Session —

Todd: In the breakout group practice you'll want to have your your handout keys to effective CBT you can see that here on the screen and um there's uh two resources the first is just a reminder of the skills um for accountability on page three but then on on page four if you had page four handy um pull that out and one person is going to read one of the patient statements you have a volunteer that will do that and your job is just to read the the patient you don't have to come up with anything the therapist will then respond and try to include the three things that we've talked about the state what you have to offer the the carrot dangle the clarifying what will take the gentle ultimatum and then asking for commitment with sitting with open hands and then you stop right there and your group leader will give you a little bit of feedback what did they like and you know how you could maybe tweak or improve it and then you can practice it again with the improvements and hopefully you get through you know two or three maybe even four uh practice rounds with one person in in five minutes and then switch roles uh so that as many people can get get practice as possible and so we want to do a little bit of a demo we're going to invite zanen to open up his mic and I wonder um LJ can you sp beautiful Spotlight Zane uh one of our brilliant brilliant colleagues uh and Zane is going to play the role of the patient Joe will play the therapist and I will play the role of the kind of group leader providing a bit of feedback to model what you're going to be doing when you go into the breakout groups and I'll just also add that while you're watching our brief demo uh pay attention to what I'm doing and see whether you think I'm hitting the mark on all three whether missing you know if you were giving me feedback what kind of feedback would you be giving me and that's the best way to learn as well and when you're in your breakout group if you're not actively demonstrating you're we want you to be taking notes on what the person's saying and you're rating in your head did they do the carrot did they do the ultimatum did they ask for commitment and that's just the best way for you to get really engaged in the learning um okay so I think Zane is gonna be the patient um reading that patient statement and then I'm gonna demonstrate being the therapist and then Mike is gonna be my trainer and give me some feedback thanks so much Zane for volunteering and you can go ahead and read the patient statement you know I really want to overcome this anxiety in the talk therapy I tried before it it didn't really seem to help great so I'm gonna assume that I've done plenty of empathy in this call as well right so we I often will say empathy empathy empathy like I've done a lot of listening um so Zane yeah I I um I'm glad you've been sharing with me about this social anxiety that you've been struggling with and I want to let you know that I would love to work with you I think we'd be a really good fit I have a lot of really great tools um to help you and and other patients overcome social anxiety and I think um we could totally get there together I I also want to be really honest with you about you know what it's like to work with me and kind of what it's going to take to to get those you know really good outcomes in in our therapy together and so one of the things it may seem kind of simple but I am going to ask you to come to therapy weekly even when you're busy and things are going on in your life that that kind of a good dose of therapy is weekly therapy so I want to make sure that you're able to to come weekly and meet with me weekly um I'm also gonna ask you to use some measures and fill out some measures over the course of therapy so you and I can make sure that you're getting the help that you want that we're staying on track and and that you're getting better kind of holding us accountable and also I'm going to ask you to do some homework between sessions I'm going to give you some things um that will stem from the work we're doing in session to practice right so that you can really kind of learn skills and tools and Implement them between sessions so that you can get better and um so I just wanted to to tell you about that awesome and stop and pause right there excellent Jill I I loved your carrot dangle at the beginning you said love love to work with you I think it will be a great fit I've got some Fantastic Tools um stating what you had to offer and and you also very clear on three things the weekly sessions the measures and and then the homework um I'm wonder if you could try it one more time and make sure you ask for commitment this time um at the end okay Zan would you read that patient statement one more time I want to overcome this anxiety but the talk therapy I tried before just didn't really seem to help okay so I'm going to again remind myself that I did a really good job of empathizing with you already so I don't go into that um and and yeah Zane um you've been telling me um that you've been struggling a lot with social anxiety and I want to let you know that I'd love to work with you I think we'd be a really good fit and I have some really good tools to help you to overcome your social anxiety and I think we could do some really great work together um I also just want to be totally hon honest with you and share with you what I think it's going to take on your end and what it would be like to work with me and so one of the things that's super important is just to make sure that you feel like you can commit to coming to therapy weekly um I know that you're busy and um you know busy dad and and working hard and have kids at home and so I just want to make sure that you're going to be willing to to make the space in your schedule and meet with me weekly um I also want to just share with you that we um will be using measures as part of therapy so I'm going to have you come in and just fill out a measure of your symptoms before and after your sessions in the waiting room and we'll use those measures to make sure that we're um making the progress that you want to make and that'll be really help uh important to to therapy and and finally I'm going to make sure that you're willing to do some homework um I'm going to be giving you some um exercises that I want you to be practicing things I want you to be practicing outside of session that will really enhance the work that we're doing together it'll be directly related to what we're doing inside session and just make sure that you're making some changes in your life between sessions um and I know that sounds like a lot it's kind of a mouthful so I want to check in with you now and ask you do you feel like does that sound good are you willing to do that work with me um uh or I also want to be respectful and say you know does that not sound like the kind of therapy that that you're looking for so tell me what you think are you excited to do that work with me and pause right there beautiful so that was a beautiful carrot dangle and then the gentle up and and then you added that commitment uh question at at the end so before we go to breakouts just a reminder um if you go to the next slide Jill of what our plan is one person will choose there's three patient statements to

Mike: In the breakout group practice, you'll want to have your handout keys to effective CBT. You can see that here on the screen. There are two resources: the first is just a reminder of the skills for accountability on page three, but then on page four, if you have page four handy, pull that out. One person is going to read one of the patient statements. You have a volunteer that will do that, and your job is just to read the patient. You don't have to come up with anything.

The therapist will then respond and try to include the three things that we've talked about: stating what you have to offer, the carrot dangle, clarifying what will take, the gentle ultimatum, and then asking for commitment with sitting with open hands. Then you stop right there, and your group leader will give you a little bit of feedback on what they liked and how you could maybe tweak or improve it. Then you can practice it again with the improvements, and hopefully, you get through two or three, maybe even four, practice rounds with one person in five minutes, and then switch roles so that as many people can get practice as possible.

We want to do a little bit of a demo. We're going to invite Zane to open up his mic, and I wonder if LJ can spotlight Zane, one of our brilliant colleagues. Zane is going to play the role of the patient, Joe will play the therapist, and I will play the role of the kind of group leader, providing a bit of feedback to model what you're going to be doing when you go into the breakout groups.

Jill: I'll just also add that while you're watching our brief demo, pay attention to what I'm doing and see whether you think I'm hitting the mark on all three, whether I'm missing anything. If you were giving me feedback, what kind of feedback would you be giving me? That's the best way to learn as well.

When you're in your breakout group, if you're not actively demonstrating, we want you to be taking notes on what the person's saying and rating in your head: did they do the carrot, did they do the ultimatum, did they ask for commitment? That's just the best way for you to get really engaged in the learning.

Okay, so I think Zane is going to be the patient, reading that patient statement, and then I'm going to demonstrate being the therapist, and Mike is going to be my trainer and give me some feedback.

Mike: Thanks so much, Zane, for volunteering, and you can go ahead and read the patient statement.

Zane: You know, I really want to overcome this anxiety in the talk therapy I tried before. It didn't really seem to help.

Jill: Great. So I'm going to assume that I've done plenty of empathy in this call as well, right? So I often will say empathy, empathy, empathy, like I've done a lot of listening.

So, Zane, yeah, you've been telling me that you've been struggling a lot with social anxiety, and I want to let you know that I'd love to work with you. I think we'd be a really good fit, and I have some really good tools to help you overcome your social anxiety. I think we could do some really great work together. I also just want to be totally honest with you and share with you what I think it's going to take on your end and what it would be like to work with me. So one of the things that's super important is just to make sure that you feel like you can commit to coming to therapy weekly. I know that you're busy, a busy dad, working hard, and have kids at home, so I just want to make sure that you're going to be willing to make the space in your schedule and meet with me weekly. I also want to share with you that we will be using measures as part of therapy, so I'm going to have you come in and just fill out a measure of your symptoms before and after your sessions in the waiting room. We'll use those measures to make sure that we're making the progress that you want to make, and that'll be really important to therapy. Finally, I'm going to make sure that you're willing to do some homework. I'm going to be giving you some exercises that I want you to be practicing, things I want you to be practicing outside of session that will really enhance the work that we're doing together. It'll be directly related to what we're doing inside session and just make sure that you're making some changes in your life between sessions. I know that sounds like a lot. It's kind of a mouthful, so I want to check in with you now and ask you, do you feel like that sounds good? Are you willing to do that work with me? Or I also want to be respectful and say, does that not sound like the kind of therapy that you're looking for? So tell me what you think. Are you excited to do that work with me?

Mike: Pause right there, beautiful. That was a beautiful carrot dangle, and then the gentle up. You added that commitment question at the end. So before we go to breakouts, just a reminder. If you go to the next slide, Jill, of what our plan is.

One person will choose. There are three patient statements to choose from. One person will play the role of the patient and read one patient statement. Then the person playing the therapist responds. You can start by saying, "Empathy, empathy, empathy, if that helps make you feel like you've done that because you don't need to go into that fall. You're going to imagine you've done all of that already. Then, using the three criteria, state what you have to offer, what it's going to take, and then ask for commitment. Your group leader will provide a little bit of feedback. You'll notice that when I gave feedback, it was very, very brief. A couple of things that were done well, and then one area of improvement. So we kind of aim for a four-to-one practice-to-feedback ratio. More practice is always better.

After about five minutes when you're in the role of the patient or therapist, then switch roles with somebody else in your group. There's no pressure requirement to engage. We do encourage you to dive in with the practice, even if this feels a little new and unfamiliar. Dive in and see if you can get even just one of the criteria with one round and then add another one the next round, and then add the next one. Certainly, your group leader can do a little modeling if you need a bit of a nudge or support in that. Anything you want to add to that before we go to breakout groups, Jill?

Jill: Just one, maybe two points I wanted to add. One is that it is really important to find your own language. We're not just encouraging you to parrot here. When we say clarify what it will take, I said three things. You don't have to say three things. If you're not actually requiring measures in your patients, then don't say that. We want you to practice what you're going to use in your therapy next week, the week after.

For the leaders as well, know that not everybody's going to have the same criteria. We want you to use the criteria that seem appropriate to you. The other thing I was going to say is just people might notice these practice groups. We're trying to make them really streamlined and clear. That's based on feedback we've gotten from you guys. Sometimes, without this kind of clarity and guidance, the practice groups can be kind of vague, and people don't get a chance to practice.

We'll be looking for your feedback today too on how this goes for you with really clear criteria and kind of direct feedback and moving pretty quickly so that more and more people get a chance to practice the skills. I'll ask for Daniel Herman. Daniel's going to be sending you guys into your breakout group. Let me check in with Daniel. You can let us know if you're ready, and just one more thing. I think Daniel will remind me to say this, so do not get out of the large group meeting. You're just going to stay logged in for the entire time. We want you to stay logged in exactly where you are till 1 o'clock till the end of the workshop today.

That is because Daniel will assign you to a breakout group, and that's the same group you're going to return to for additional practice throughout the day. If for some reason you get bounced out, not by your own doing, you land back here, then we'll make sure we get you reassigned to your breakout group. You're going to have 30 minutes to practice these skills with the help of a leader. Daniel, are we good to go?

Daniel: Yeah, all set, and thanks for that reminder. Of course, if someone does get booted off somehow, you can just remember either the group number or your group leader. That will help us get you reassigned. We're saying when you land in your breakout group, maybe just jot down the name of the group leader or your group number. If for some reason you get booted out by Zoom, we'll put you right back where you belong. Make sure you have the handout printed in front of you. We're going to send you off for 30 minutes, and it's 9:45 on my clock. I gather that means we'll be getting back together again at 10:15. Okay, great.

— Practice Break —

Jill: Hoping that you learned a lot and practiced and got a feeling for what it's like to be the therapist and a little bit of what it's like to be the patient as well. Actually, what we'd really like to do is hear from you about what your breakout group was like, what you learned, and we have a couple of questions to guide you. First, we're curious if you played the role of the patient, how did it feel to be held accountable? As the therapist, when you were in the role of the therapist, what did you find most challenging? You can share more than that with us, but these are just some ideas to get you started. If you'd like to share your thoughts with us, which we hope you will, we want you to send a little note in the chat box to Zane, and you can just say, "I want to share," and then we'll unmute you actually, and then you can communicate with us and share. We'd really love to hear what you learned and have a little bit of a conversation with you about that before we move forward with the rest of the teaching. We'll give you a minute to send a note to Zane, and then Zane's going to find you and unmute you, and then we'll chat with you.

— Live Discussion —

Jill: We're going to move forward, and again, this kind of framework, the carrot, the gentle ultimatum, and sitting with open hands, is going to be something we keep coming back to throughout the morning. So not to fear, we're not actually finished with it yet. We talked about that first obstacle of patients not really knowing what to expect and how we solve that with the 15-minute phone consultation conversation. Another obstacle that we all really struggle with, related to accountability, is when our patients go on and on, or when our sessions, I should say, go on and on in an unfocused way.

Many therapists that I train ask that question: How do you keep your sessions on track? How do you keep your patients focused? So, we'll run a poll now. Let me run that for you, and we want to know, when sessions do kind of go on and on in unfocused ways, what do you do? Do you interrupt your patient when they start going on and on? Do you ask them open-ended questions to understand more about what they're talking about? Do you offer helpful suggestions to whatever they're bringing up that day? Or do you raise your rates so that they realize how valuable therapy time is? I'll give you another 30 seconds or so. We only have about half of you having completed the poll, so just go ahead and click what you tend to do when this happens.

Okay, I'm going to end the poll and share the results so you can see. About 52% of you, about half, said you interrupt and redirect. Another 35% said you ask open-ended questions. 11% said you offer helpful suggestions, and one of you, perhaps tongue in cheek, said you raise your rates so they realize how valuable therapy time is. Great, so lots of you with interrupting and redirecting, and a good amount of you with asking open-ended questions.

Let me also say that when I ask therapists this, like what do you do when your patient goes on and on, a lot of therapists, and actually I would fall into this camp, might say, "Well, sometimes I interrupt them and redirect them because in my mind, we've got to get to work. Other times, I just listen to them in the therapy session and kind of go wherever they go. Sometimes, I alternate between the two. Sometimes, I'm really eager to get to work, so I'm kind of very directive. Then, I get feedback that I'm too directive, so then I pull back." What we're going to offer you now is a framework for responding to this kind of meandering session that we think will really help you to stop yourself from just stopping the patient and course-correcting forcefully, but also not just following them in an aimless way.

The invitation step is where we invite the patient to pause and ask them if it's time to get to work. Pick something specific to work on without bulldozing and forcing them to do that, which ultimately would lead to resistance. Imagine your patient is going on and on about something, and you say, "So anyway, panic disorder, right?" That's going to feel kind of pushy and probably set things on the wrong track. On the other hand, if you just listen and don't interrupt at all, you probably won't ever really get to the work of therapy. So the goal of what we call the invitation step is, again, to hold yourself and your patient accountable for moving from the empathy phase of therapy, where you are listening and allowing the patient to share how they're thinking and feeling, into the change-focused phase while making it clear that the patient has a choice. We want to be clear as cognitive behavioral therapists that we don't think that empathy alone is enough. We think it's necessary but not sufficient for change. So there's always going to come a time, even when we've been empathizing, that we're going to need to shift gears and figure out if it's time to get to work.

With the invitation step, our goal is to listen to the patient, offer them empathy, and then ask if they are ready to roll up their sleeves or shift gears and get to work. You don't have to use those phrases, but it's about asking if they're ready to focus on something specific. We are giving them a choice, like Adam said, sitting with open hands, so that they can choose if they are ready to get to work or if they feel like they need more time to talk and for us to offer some support. I'm just checking to make sure it's still my turn to talk here.

Why would you do the invitation step? As I said, we really want to communicate to our patients gently that listening alone will not be sufficient. If we pause and say, "You've talked to me about A and B and C, and I'm wondering if now would be a good time for us to shift gears and pick one of those things to work on," that phrasing alone is showing them there's something more I have to offer than just listening and support. I'm communicating that that's not enough. The active effort of shifting gears, picking something, and working is necessary, but it also gives the patient permission to talk more if that's needed because I don't actually know when my patient is ready to get to work. I don't know if there's something else on their mind that they maybe haven't even told me that feels essential to share. It puts the patient in charge but still holds them accountable, and it reduces the "yes, butting," meaning if we are clear to the patient that there's a choice here, and they can choose which way, we're not telling them what to do. We don't end up with them saying yes but then actually resisting later on. Our goal is to be really open and transparent about the process.

Mike has a story to share that kind of demonstrates the importance of the invitation step.

Mike: One of the questions that came up for me when I was learning this, and often comes up in training, is when do you offer an invitation? When do you do it? If we look at the team model, the testing and then the empathy is so key and critical. We want to make sure we're listening and really connecting. But then when do we offer the invitation, shift into that assessment, resistance, agenda-setting? I struggled with this early on and would lean towards more empathy rather than less. In one session, I was trying to work on doing my invitation a little bit better. I think we probably had a class that week, and I thought, "Okay, this week I'm going to do better at the invitation." This particular client was a great guy, loved to talk. He was talking, and I would say, "Oh yeah, tell me more. How does that feel? What's that like for you?" Then he would talk some more, and it was getting a little bit later in the session. I finally thought, "Oh, I've got to do an invitation." I said, "Hey, you've been talking about XYZ, and I'm wondering if now would be the time for us to make a bit of a shift and get to work on something."

His response was powerful for me. I'll never forget it because his response was, "Well, I was wondering when we're going to get to work on something." It was such a powerful reminder to me that if you offer the invitation in a very open, gentle, and warm way, even if you do it early, that's okay because they can still choose to continue to talk. But offering it late can be a real error because they may be wanting to get to work, and you're making the decision for them by waiting longer. It was a powerful one for me to say, "It's okay to actually offer an invitation a little earlier in the session."

Jill: I have one more story about the invitation that I'll share with you guys too that kind of addresses this "when and early and often" concept. I had a patient I was working with who had bipolar disorder. We were working well on his depression, this particular piece of it. He was on medication as well, but he also was going through a divorce. The divorce really wasn't super relevant to what his depression was about, a lot of low self-esteem and achievement addiction and things, but it was happening simultaneously. We had been working really well together in a focused way. And then there was stuff going on with the divorce, and he was super mad at his soon-to-be ex-wife. So, he would come into the session and sit down, and before I really had a moment to look at his measures or say anything, he would just go on and on about how pissed off he was at his ex-wife.

You know, when your patient is talking about how mad they are at someone, you feel like you need to empathize. So, I was listening and offering him support, but in the back of my mind, I'm like, "Okay, when are we going to get to work on the stuff you came here for?" But I would listen and offer empathy, and then I would say, "You know, at some point, I would kind of say, 'So Mark, you've been telling me about how angry you're feeling at your ex-wife, and I just wanted to pause for a moment and ask, would now be a good time for us to shift gears and start to get back to working on what we've been working on before? Or do you feel like you need more time in session today to share with me just how frustrated and angry you're feeling?'" And he would say, he said the first time I said that, he's like, "Oh no, I'm done. Let's get to work, right?" So, I thought, "Oh great, thank goodness. Okay, we're good. Now we're just gonna work on his depression." And then the second, the next session after that, he came back and started doing the same thing again. I thought, "Oh man, I gotta interrupt him again." And so, he starts talking about his ex-wife and how angry he is. So, I kind of roughly say something very similar, and he's like, "Oh yeah, no, no, no. Honestly, I'm done. I can talk to, I got friends I can talk to about my anger. Like, I really want to work with you on my depression."

But invariably, he would come back, and I had to do the same thing. So, what happened was I ended up like maybe three sessions, and I kind of, you know, probably shifted in my chair, and I said, "You know, so Mark," and he goes, "I'm ready to get to work." So basically, I had trained him through my very gentle interruption and my empathy, kind of what was next. And so, he said, he himself said, "I got to stop this. Like, this is not how I want to be using my therapy time. Like, you've been very kind to listen to my ranting, but I got other people I can rant to, right? Like, I'm paying you too much money to rant here. Like, let's get to work." And then I could much quit more quickly with his permission, kind of when he would come in, be like, "Okay, so we're not ranting, right? We're going to work on your depression."

So again, these are processes, the invitation, the accountability that we use in our therapy sessions, and our patients even start to get to know them and appreciate them, I think.

Mike: So, you'll notice in some of the things that Jill was saying that, and we're going to touch on these three components of the invitation.

You start with a little bit of empathizing, right? A little bit of a summary of what they've been experiencing. So, you feel that connection still. Then we move to a gentle, subtle carrot dangle “Love to help you”, “You've got some great tools to get to work” and the key is actually giving that invitation. Is now a good time to get started? Would you need more time to talk before we roll up our sleeves and get to work?

And in Jill's example, each week she would do a little bit of that empathizing, right? She'd say, "I'd love to actually get back and get you some more relief from what you're talking about. But would now be a good time for us to do that?" And you know, trained, in a sense, Mark, I think, who we're calling him that. Yeah, this is an opportunity for doing something more. And so when we work with the invitation, it's to me actually a deeper empathy tool as well. You're still connecting with them, but then you're also offering them an opportunity and showing them that there's more that can be done here. Examples might include, "You know, Claire, you've mentioned problems with depression, anxiety, procrastination at work, and I can see how much pain these difficulties are causing you." It's the empathy component. "And I'd like to offer you more than just listening and support. And I believe we could solve these problems if we work together." Carrot dangle. "I'm wondering if you'd like to get to work on one of these problems today, or if you need more time to talk and have me listen." The invitation with Open Hands. Another example could be, "You know, you've been telling me about the difficulties in your marriage to Susan and about the stress and anxiety that you're having at work. I want to check in with you now. I'm wondering if you feel like you need some more time to talk and get support, or if you feel like now would be a good time for us to roll up our sleeves and start to work on one of these problems. I'd love to help you with your anxiety or your relationship, and I know we can do some great work together. But I also don't want to push you to get to work before you're feeling ready."

Jill: There's a lot to say on this slide. Mike, no, I'm just kidding. So, we, right, we're going to give you guys a 10-minute morning break. And then when we come back from our break, we're going to keep telling you a little bit more about the invitation and talk a little bit about what happens when the patient kind of says “yes, but” and kind of talk over you, which is what often happens even when we do a really excellent invitation step.

— Break —

Jill: So we talked to you about what you do when you offer the invitation to your patient, and of course, in the ideal scenario, the patient says, "Oh yeah, no, I love to get to work," and they just stay on track for the rest of your course of therapy. But we all know that that does not always happen, and sometimes patients will say, "Yeah, I'd love to get to work," and then kind of pause and let you direct them and figure out what to work on, and that's fantastic. But sometimes patients will give you what we call the "yes but&