Presence, immediacy, and transparency: what do they have to do with CBT?

CBT is fundamentally a phenomenological approach emphasizing individuals’ subjective interpretation of experiences and construction of personal meaning structures (Beck et al. Reference Beck, Rush, Shaw and Emery1979). Patients’ first-person accounts, which are unsullied by clinicians’ interpretations are prized. Moreover, at its core, CBT with youth is an emotionally rousing and interactive approach (Friedberg & Brelsford, Reference Friedberg and Brelsford2011). Emotional alertness is positively associated with favourable ratings of the treatment alliance (Karver et al. Reference Karver, Shirk, Handelsman, Fields, Crisp, Gudmundsen and McMakin2008). An emotionally present cognitive behavioural therapist appears especially credible due to increased transparency and immediacy. Presence is characterized by therapists’ appropriate transparency and ability to authentically remain in psychological contact with patients and their emotionally potent phenomenological experiences (Greenberg, Reference Greenberg, Gilbert and Leahy2007; Geller & Greenberg, Reference Geller and Greenberg2012).

As the third-wave CBT advocates of Acceptance and Commitment Therapy (ACT) argue, ‘Life only happens in the present moment’ (Pierson & Hayes, Reference Pierson, Hayes, Gilbert and Leahy2007, p. 221). Simply, immediacy in CBT means attending to what is happening right in front of clinicians. Cognitive behavioural psychotherapists seize these robust therapeutic moments. Immediacy pervades clinical practice of CBT. For instance, therapists are taught to ask the cardinal question, ‘What is going through your mind, right now?’ at the immediate moment of a young patient's mood shift. When clinicians attend to in-session mood shifts, they are embracing immediacy. Certainly, good Socratic methods, behavioural experiments, and exposures are the ultimate immediate experiences.

Pierson & Hayes (Reference Pierson, Hayes, Gilbert and Leahy2007) added,

Transparency and empiricism are intertwined in CBT with youth. Both serve to reduce the mysterious nature of psychotherapy as well as reduce power differentials between patients and therapists. Granting genuine informed consent is made easier by transparency and empiricism. When transparency is integral to every practice in CBT, patients are able to grant consent in each session multiple times. Obtaining informed consent can become a rote procedure. Patients are given vague or generalized descriptions of procedures at the first session and then often therapists might forget to check back in. The collaborative check-in process, so fundamental to CBT, operationalizes transparency. Cognitive behavioural psychotherapists join forces with young patients and ask them directly how therapy is going for them or whether they are willing to experiment with different procedures. For instance, transparent cognitive behavioural therapists will let young patients know they will be making an emotionally provocative statement (‘This may piss you off but . . .’). Additionally, before cognitive restructuring procedures are practised, transparent and immediate cognitive behavioural psychotherapists assess patients’ willingness to proceed (e.g. ‘Now that we have grabbed hold of your thoughts, how willing are you to test them out?’).

Therapeutic transparency is augmented by authenticity. In the classic Brian De Palma (Reference De Palma1983) film Scarface, there is a great line which defines authenticity. A drug lord, Alejandro Sosa, tells aspiring gangster Tony Montana, ‘I like you Montana; there is nothing false in you.’ Good authentic and transparent cognitive behavioural therapy is highly interactive. Padesky (Reference Padesky and Salkovskis1996) emphasized that clinicians who are not comfortable in a highly interactive psychotherapeutic process are not good candidates for cognitive therapy training. Therapeutic presence augments this authenticity and creates a genuine readiness to act

Some readers may see similarities to procedures such as mindfulness (Coyne et al. Reference Coyne, McHugh, Martinez, Peters and Freeman2011; Semple & Burke, Reference Semple, Burke and Kendall2012) and radical genuineness (Klein & Miller, Reference Klein, Miller, Peters and Freeman2011) with youth. Mindfulness and radical genuineness may be best described as practice elements whereas presence, immediacy, and transparency are therapeutic stance variables. Indeed, these widespread and popular methods used in ACT and Dialectical Behaviour Therapy are founded on the seminal processes of therapeutic presence, immediacy, and transparency. For example, therapists’ mindfulness fundamentally requires presence and immediacy. Radical genuineness by a therapist demands transparency. Presence, immediacy, and transparency are associated with methods such as mindfulness and radical acceptance but are not limited to them or any other specific technique. Rather, they are integral to all cognitive behavioural practices and cut across all the therapeutic modules

Carpe presence, immediacy, and transparency in CBT with youth

A modular approach (Chorpita et al. Reference Chorpita, Daleiden and Weisz2005; Friedberg & Brelsford, Reference Friedberg and Brelsford2011) to delivering CBT is gaining favour. The modular approach also seems very consistent with the emerging transdiagnostic treatment model (Ehrenreich et al. Reference Ehrenreich, Goldstein, Wright and Barlow2009). Simply, in the modular approach, essential components to treatment are extracted from manuals then systematically applied based on case conceptualization and clinical indications. Modules represent different broad categories of interventions which are comprised of specific techniques. Typical modules are self-monitoring, affective education, behavioural interventions, cognitive interventions, and experiments/exposures. The following sections illustrate the way presence, immediacy, and transparency may be exercised in self-monitoring, cognitive restructuring, and experiments/exposures.

Self-monitoring

Self-monitoring is central to CBT. Self-monitoring may be accomplished by standardized measures and/or individualized thought diaries/behaviour logs. While completing a thought diary is a basic and commonly used procedure, a nuanced application requires therapeutic presence. Ideally, thought diaries are not mechanistic dry techniques separated from patients’ immediate experience. The best time to use a thought diary is when patients experience strong negative affective arousal. More precisely, they are immediate, present-focused, emotionally evocative clinical tools. They should be used when patients are experiencing mood shifts.

Consider this example. Tasha is a 14-year-old Latina female who is socially anxious, approval seeking, and highly perfectionistic. Her core belief system reflected a view that unless she was absolutely approved of by others, regularly ‘perfect’, others would see her as weak and she would be a ‘worthless wimp’. Not surprisingly, Tasha arrived at sessions carrying typed daily thought records written in a precise and pristine manner. The therapist then intervened with immediacy and transparency based on his conceptualization.

In this exchange, the therapist socratically processed the thought record with therapeutic presence, immediacy, and transparency. He elected to focus on Tasha's immediate perfectionism and approval-seeking which was contingently tied to her appraisal of self-worth.

Consider another example. After completing a Beck Depression Inventory (BDI) and handing it to the therapist, a 16-year-old Euro-American female patient appeared sullen and angry staring at the therapist with fire in her eyes. The therapist alertly seized the moment and asked, ‘Lexi, what is going through your mind, right now?’ Lexi replied, ‘You care more about that fricking BDI than you do me.’ At this point, the therapist used a thought diary to process this transaction.

The dialogue illustrates several very worthy points. The thought diary came to life during the interaction between Lexi and the therapist. Therefore, the technique became a centerpiece in the work. Second, the therapist maintained presence and focused the self-monitoring with the here-and-now with his statements (e.g. ‘And you feel?’; ‘What is running through your head now when you are so angry?’) Finally, by doing a thought diary on Lexi's urgent expression (e.g ‘You care more about that paper than you do about me’.) as well as writing thoughts and feelings down on paper, the therapist transparently communicated that Lexi's experiences are so serious that they are noted verbatim. Accordingly, the therapist demonstrated immediate responsiveness.

Cognitive restructuring

Cognitive restructuring renovates children's maladaptive thinking patterns. Nonetheless, re-engineering children's internal dialogues is never an easy task. The emotional currents of their thoughts and images need to be activated otherwise therapy risks being overly abstract and intellectualized. Moreover, without transparency, immediacy, and presence, cognitive restructuring takes on an interrogatory flavour or becomes another lecture by an adult. However, when cognitive therapists embrace transparency and immediacy in their therapeutic stance, cognitive restructuring catches fire.

Greg is an 11-year-old Euro-American male who carries the diagnosis of high functioning Asperger's disorder. Not surprisingly, Greg miserly held onto his beliefs with unwavering determination. However, presence, immediacy, and transparency decreased his unyielding attitudes. Below is a description of the therapeutic process.

The therapist fuelled by a present stance caught Greg's perception of being judged. Moreover, Greg voiced blind faith in his perceptions (e.g. ‘I know where this going and it's not going to help.’). Transparency enabled the therapist to authentically respond to this belief (e.g. ‘Where do you think this is going because I am not sure myself?’). The therapist then used immediacy to test his hypothesis (e.g. ‘Do you want to check out this prediction?’). The therapist responded transparently in the session when Greg experimented with testing out his hypothesis. Additionally, the therapist used immediacy in the session to facilitate his cognitive restructuring (e.g. ‘How do you know I am being honest with you, right now?’; ‘What is it like for you to test these thoughts rather than just believing your own guesses?’).

Behavioural experiments and exposures

CBT is action-oriented. Padesky (Reference Padesky, Bennett-Levy, Butler, Fennell, Hackman, Mueller and Westbrook2004) eloquently explained that the fundamental task for cognitive behavioural psychotherapists is to bring the head and heart to consensus. Waller (Reference Waller2009) urged cognitive behavioural therapists to rely more heavily on action-based strategies rather than purely verbal interventions. Indeed, frequently talking about problems and solutions is overvalued. Genuine change and authentic mastery regularly call for reasoned action.

Therapeutic presence and immediacy are especially vital during behavioural experiments and exposures. Karver et al. (Reference Karver, Shirk, Handelsman, Fields, Crisp, Gudmundsen and McMakin2008) added that therapists’ application of experiential strategies improved therapeutic relationships with adolescents. Therapeutic presence boosts behavioural experiments. When therapists demonstrate their undivided attention during an exposure, patient engagement in the task is increased (Friedberg et al. Reference Friedberg, Gorman, Hollar, Biuckians and Murray2011). Experiments and exposures make new thinking patterns more credible. Without experiments and exposures, young patients must blindly base their new conclusions on verbal persuasive methods. Behavioural experiments and exposures precisely provide this good clinical recipe. Behavioural experiments and exposures are typically graduated and applied with alert sensitivity to the delicate calculus balancing the intensity of emotional challenge with young patients’ coping capacity.

Misty is a 12-year-old Latina female who struggles with perfectionism. Misty became very anxious at the prospect of any mistake. She and her therapist designed several behavioural experiments. One specific experiment involved purposefully dialling a wrong number on her cell phone. Misty misdialled the number in session and became extremely anxious. The following dialogue illustrates the process.

The therapist's presence enabled instant processing of Misty's thoughts, feelings, and behaviours. Transparency was realized throughout the dialogue (e.g. ‘You looked worried right after you hung up’; ‘That's exactly what we wanted to happen’). Immediacy was achieved during the experiment (e.g. ‘What's going through your mind, right now?’; ‘Let's sit with this’; ‘What did you learn from this?’).

Declaration of Interest

None.