Gayle Y. Iwamasa's theoretical approach is based in cognitive–behavioral theories of the development and maintenance of thoughts, feelings, and behaviors. This approach allows for the development of a testable case formulation based upon information provided by the client, as well as an easy-to-understand summary of how therapist and client will collaborate effectively to address the client's concerns.
Further, the cognitive–behavioral formulation points the therapist to potential specific interventions that would benefit the client. Thus, this approach provides a nice "package" of treatment that can be communicated to the client at the very first session. The client is able to have an understanding of how the therapist plans to work with him or her (collaboratively), what they will work on together, and how the therapist proposes to do it. This engenders hope and optimism and confidence in the therapist's ability both to understand the client's experience and to develop and implement a reasonable plan to address his or her concerns.
Cognitive–behavioral therapy (CBT) is very easy to explain, understand, and monitor. In a typical first session, in introducing the case formulation, Dr. Iwamasa uses a presenting concern as an example to explain how thoughts, feelings, and behaviors are interrelated. Concepts such as the client's automatic thoughts and behaviors are discussed.
She then uses that same example to demonstrate a few ideas on how she and the client could work together using cognitive (e.g., cognitive restructuring or thought records) and behavioral (e.g., moving the alarm clock across the room) interventions to change feelings (e.g., depression). Oftentimes, while a therapist is presenting the case formulation, the client is able to come up with his or her own ideas and suggestions for interventions, which increases buy-in.
All interventions can be documented and tracked and therefore, monitored for effectiveness. Both the therapist and the client will know if an intervention is working by looking at the data together.
Speaking of data, use of documentation in therapy is an excellent approach to demonstrating to clients not only that they are making progress, but that the therapist is able to articulate specific areas in which progress is occurring.
This frequent visiting of successes reinforces the client's motivation and optimism to continue to progress. It also allows for discussion of what specific aspects of therapy are beneficial and is helpful in determining when problems have been sufficiently addressed. The client can then make informed decisions about whether to change the focus of therapy or discontinue therapy if he or she is satisfied with current functioning and life situation.
The beauty of CBT is that concepts and interventions can be introduced and customized to the client's specific issue, explained, learned and practiced, all within the therapy session. The therapist introduces the concept, teaches the client skills, and then practices them in session until the client experiences a level of confidence about being able to complete the intervention on his or her own, assign homework (out-of-session practice), set up a schedule of reinforcement for completing the homework, and so on.
One extremely effective example of this is the use of exposure for anxiety-related conditions. The therapist can start by discussing the client's specific experience of anxiety and identifying their specific triggers and symptoms, which in turn help to identify potential interventions specific to their triggers and symptoms.
For example, if a trigger is a visual stimulus that prompts a specific thought, the client can be taught various cognitive strategies such as thought stopping, cognitive restructuring, or the downward arrow technique. Behavioral strategies could include the use of coping cards, relaxation exercises, distraction, etc.
Once the therapist and the client select the intervention, the therapist can teach the client the intervention and practice it in session, while providing feedback and verbal reinforcement as they progress. The therapist and client can then discuss what a reasonable homework assignment would be and what might get in the way. They can also discuss the reinforcer the client will implement if the assignment is completed. Practice is not relegated to in-session only. Some practitioners will even assist clients with exposure interventions outside of the therapy office (e.g., fear of bridges).
One of the best aspects about CBT is that the therapist and the client will be more likely to be on the "same page" in terms of treatment; will be able to anticipate successes and problem solve when a strategy does not appear to be working; and will be able to track progress, thus making informed decisions about the course of therapy.
Presentation of the case formulation in the first session demonstrates to the client that the therapist "gets" him or her, increasing the likelihood that the client will have confidence in the therapist's ability to help, and also helping to establish the therapeutic alliance so that the therapist and client can begin their work together.
The great aspect about CBT is that it has been found to be effective for a wide variety of people with a wide variety of problems. Because it is based on principles of learning and maintaining thoughts and behaviors (reinforcement and associative learning), and how that process of learning and maintaining thoughts and behaviors affects feelings, it is applicable to virtually any problem that can be addressed through problem solving.
Regardless of the problem, each component of problem solving — accurate problem identification, developing potential solutions, selection of potential solutions, and implementation of the solution(s) — is used in therapy to provide practical and realistic skills that clients can use to address their concerns.
Dr. Iwamasa has used CBT approaches successfully with individuals young, old, and in between, from a wide variety of ethnic and cultural backgrounds, from varying socioeconomic groups, and for vastly different problems and concerns.
The key to successful CBT is the therapist's ability to develop customized interventions to each specific client. In other words, the therapist could use the same intervention with two very different clients, and the interventions would possibly be different for each of them. Or it could be the same intervention, but implemented at a different intensity or frequency, depending on the client's cultural context and ability level.
CBT has been shown to be effective for virtually any client. The significant body of CBT research findings and therapy tools and materials available to therapists is staggering and impressive. There are even materials for traditionally "difficult to treat" clients such as those with Axis II disorders.
Because CBT is so individualized and customizable, therapy can move as fast or slow as needed, depending on the client. With some clients, the therapist may be able to introduce several concepts and practice them all in one session, while with others they may want to process and experience feelings in session prior to developing a treatment strategy to address those feelings.
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