Module 3: Nonspecific Factors in Brief CBT

Objectives

• To better understand the need for a strong therapeutic relationship in Brief CBT
• To understand the factors associated with a strong therapeutic relationship
• To learn strategies for developing rapport and maximizing non-specific factors

What are Nonspecific Factors, and why are they important to CBT?

CBT is structured and goal-directed. The context is supportive, and the techniques are paired with a
collaborative therapeutic stance. Nonspecific factors refer to the relationship components of therapy (e.g.,
rapport, installation of hope, trust, collaboration) and can be compared with specific factors that refer to the
technical aspects of psychotherapy (e.g., the actual techniques such as guided imagery, thought challenging,
etc.) Nonspecific factors are common within all psychotherapies and serve as the foundation for patient
improvement. Specific factors refer to intervention techniques unique to the type of therapy being provided (e.g.,
CBT, psychodynamic, interpersonal). Studies show that nonspecific factors are responsible for a large
percentage of the change associated with psychotherapy treatments.

When? (Indications/Contraindications)

Nonspecific factors are critical during the early stages, but important at all phases, of treatment. Strong
nonspecific factors aid in engaging and retaining patients in psychotherapy and also strengthen the technical
components of treatment. Patients who perceive the therapeutic relationship to be collaborative, safe, and
trusting are in a better position to obtain benefit from the treatment, will likely be less resistant and will be more
open to exploration and change. As treatment progresses, the therapeutic relationship should become stronger,
allowing the therapist and patient to gradually move into more complex and meaningful therapeutic issues.

How? (Instructions/Handouts)

Borrowing from person-centered therapy, this module focuses on three factors important to the development of
a strong therapeutic relationship. These factors are empathy, genuineness, and positive regard. These concepts
are defined and discussed but represent general characteristics that all therapists should seek to attain in
working with patients. Following a discussion of these principles, the concept of active listening is introduced as
a technique to better attain a solid therapeutic relationship.

Empathy (Validating the Patient's Experience)

Empathy is the ability to understand experiences from another person’s point of view. Empathy is an important
part of building rapport and facilitates feelings of trust and mutual respect between the patient and therapist. It is
necessary for the therapist to consider the concept of “multicultural empathy,” which relates to understanding
persons from other life backgrounds (ethnicity, socioeconomic status, age cohort, gender, etc.). It is impossible
for a therapist to be knowledgeable about every patient's unique background. Empathy, which at its core
consists of asking questions in a respectfully curious manner and expressing emotional understanding of the
answers received, is a solid first step towards understanding patients' unique life background. Additional reading
about cultural differences may facilitate more informed questions and better prepare the therapist for additional
questions and/or rapport development. Ultimately, the therapist has an added task of learning about the culture
of patients and appreciating life from their perspective.

Showing empathy to a patient helps to validate his or her experiences. Being critical, even subtly, of what a
patient is sharing in therapy often makes him or her feel judged and unwilling to disclose additional information.
Use validating responses to show empathy towards a patient. Validating responses are simply statements of
understanding of your patient’s viewpoint. Validating responses usually entail the therapist’s describing what he
or she heard the patient say.

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Genuineness

Genuineness is the ability to be authentic and free of dishonesty or hypocrisy. You can be professional and
express who you are at the same time. Genuineness helps build rapport and solidify a therapeutic relationship
by allowing the patient to view the therapist as a human being. It also allows patients to access the genuineness
of the therapist for credible critical feedback about progress in their functioning.

Genuineness consists of wide variety of concepts ranging from nonverbal behaviors to overt statements.
Examples of factors related to genuineness include:

Supporting nonverbal behavior includes behaviors like keeping eye contact, giving a patient your full
attention, and nodding in agreement or understanding. It’s important that these nonverbal behaviors
match what is going on in the conversation, so as not to seem unnatural or fake.

Role behavior: CBT therapists encourage patients to be active and empowered and subsequently
attempt to facilitate this development through their behaviors in therapy. Therapists that stress their
authority in and between sessions with patients can cause a patient to feel inferior or intimidated. It is
important to remember that the therapeutic relationship is one of partnership and that the therapist and
patient work together to alleviate concerns, fears, and problems in the patient’s life.

Congruence: Making sure that your words, nonverbal behavior, and feelings match each other is
referred to as congruence. Not demonstrating congruence of your feelings and thoughts can become
confusing or misleading to a patient.

Spontaneity: This concept deals with the way the therapist speaks and the timeliness of responses.
Responses and feedback provided "in the moment" are more valuable than feedback provided at a later
time. Patients are more likely to receive spontaneous messages as genuine.

Positive Regard

Positive regard simply means showing all patients the respect they deserve. It’s essential to show the patient
that he/she is valued and that what he/she has to say is important. Patients who feel that their thoughts and

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feelings are acknowledged and understood often share more and feel more connected to the therapist and the
therapeutic process.

Communicating positive regard may be harder than it seems, especially if you hold some negative beliefs about
the person you are trying to help, which can be a common experience for therapists. Sharing any negative
feelings or beliefs about your patients with your supervisor or consultant can be an excellent method to ensure
that you develop and demonstrate genuine positive regard toward your patients.

Commitment to the patient means that you are dedicated to working with the patient on whatever issues
he or she is bringing to therapy. This includes being on time, avoiding canceling the patient’s
appointments, and using all efforts to help the patient work through those issues.

Having a nonjudgmental attitude towards the thoughts, feelings, and actions of the patient is essential. It
is possible to accept and understand a perspective without necessarily agreeing with it.

Displaying warmth towards patients is a vital part of building rapport. Warmth can be displayed through
tone of voice, facial expressions and body postures, or the thoughtfulness of your responses.

The following section addresses the concept of active listening. Active listening is a useful technique to
communicate the nonspecific factors of empathy, genuineness, and positive regard.

Active Listening

Listening to your patients is the foundation of all therapeutic approaches. Listening is made up of three steps:
receiving a message, processing it, and sending it back. Therapists should attempt to remain open to all
messages from their patients (both verbal and nonverbal), and attempt to process as many messages as
possible.

Clarification: Since we all speak from our own frame of reference, messages we send to others may not
be received in the way we intended. Clarification is a useful and necessary tool for all therapists.
Clarification can be used to help simplify a message that is being sent by the patient or to help confirm
the accuracy of what the therapist thinks he or she understood.

Patient: I just do not feel like trying any more.

Therapist: Tell me more about what you mean.

Patient: I just feel like giving up.

Therapist: Do you mean giving up on your goal to complete college; or are you referring to
something different, like giving up on life and possibly harming yourself?

Patient: I am not referring to suicide, if that is what you mean, but I am feeling really depressed. Each
day seems like such a struggle, and I often just feel like staying in bed. When I said “give up,” I guess I
was referring to not wanting to face all the struggles I face in life … my school work, financial
problems, relationship problems, etc.

Notice that the clarifying statement and question helped the therapist and patient to more fully explore
her feelings and thoughts. Given this new information, the therapist is in a better position to explore in
more detail the patient's concerns and to set up targeted efforts and strategies for treatment.

Paraphrasing and Reflection: These techniques involve restating the patient’s main thoughts in a
different way or reflecting back the emotions the patient is currently experiencing to gain depth or
clarification.

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 Patient: Since my fiancé's death, I feel like every day is a struggle, and I often question whether my
life will ever get better. I just miss him so much that I think about him constantly. I don't know what to
do, but the pain is getting to be too much.

Therapist: You are really struggling to feel better, and much of your pain comes from the
grief and loss you feel from losing your fiancé. You may even be questioning whether or not
this pain will subside because it is getting unmanageable.

Patient: Yes, that is correct. I do not want you to think that I think only about the pain of losing him.
The pain I feel comes from my intense feelings of loss, but this pain is also because I miss all the
things he meant to me, and the joy he brought to my life. I am really struggling because I do not
want to let go of him, but holding on hurts so much.

In this example of paraphrasing, the therapist gives back to the patient what he or she heard, which
allows the patient to hear her own words and react with a more detailed response. The use of
paraphrasing in this example facilitated a deeper understanding of the issue but also conveyed to the
patient a feeling of being heard and understood.

Listening for Themes and Summary Statements: Often, patients express thoughts, feelings, and
behaviors that become thematic across situations. Although novice therapists may initially have
difficulties identifying this thematic content, repetition over time (e.g., across sessions) usually helps to
create a clearer picture of the salient therapeutic issues that require attention or focus. With experience,
therapists become more effective and efficient at identifying thematic content.

Once identified, thematic content can be a very powerful mechanism to influence treatment outcomes.
Summarization is the technique that brings thematic content into the purview of the patient.
Summarization is a condensed phrasing of the patient’s responses over a specific period of time (e.g.,
across the session, since the outset of treatment, since the onset of his/her current difficulties). You
should rephrase the themes, and repeat them back to the patient for clarification.

Barriers and Challenges to Building an Effective Therapeutic Relationship

Setting limits in an empathetic manner is an essential tool for new therapists. Many new therapists desire to
“make it all better,” in that they may coddle and console the patient and are distracted from working on deeper
issues. A therapist can create a holding environment through empathetic words and active listening. A holding
environment is a setting in which the patient feels like he or she is being heard and that he or she is in a safe
and secure place to voice thoughts and feelings without judgment.

Moving from rapport and relationship building to assessment and goal setting can be challenging. When
therapist and patient are “on the same page,” this transition appears seamless. Often, however, patients and
therapists are not speaking the same language. For example, a therapist may feel most comfortable when
tackling a certain issue first; whereas a patient may wish to focus on a different problem first. When the therapist
and patient are not in congruence regarding goals, the move between rapport building and goal setting is
strained. To overcome this issue, therapists are encouraged to use motivational interviewing strategies (see
Rollnick, Mason, Butler – Chapters 3, 4, and 5). Primary techniques involve listening to the patient, following the
patient's lead and/or motivation, and setting collaborative and mutually agreed-upon goals. A vital aspect to
transitioning from rapport to goal setting involves assessing the importance, confidence, and readiness of the
patient about specific treatment goals (see Goal Setting, Module 6).

Supplemental Readings

Beck, J. S. (1995). Cognitive therapy: Basics and beyond. Chapter 3. New York:
Guilford Press.

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 Cormier, W.H. & Cormier, L.S. (1991). Interviewing strategies for helpers: Fundamental skills and
cognitive behavioral interventions, 3rd edition. Chapters 2, 3, 4, 5. Pacific Grove, CA: Brooks/Cole Publishing
Company.
Rollnick S., Mason, P., & Butler, C. (1999). Health behavior change. A guide for
practitioners. Chapters 3, 4, 5. New York: Churchill Livingstone.

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