01 - 10. Structuring Sessions
10. Structuring Sessions
B ecause you have so much to cover in Session 1, it has a different format from the rest of the sessions. We find the format described in this chapter to be the most efficient and effective way to conduct treatment. Having said that, it’s important to deviate from the structure if you find the client is uncomfortable with it. In this chapter, you’ll read excerpts from Abe’s fifth session, and you’ll find the answers to these questions: How do you determine the content of sessions? What happens in each part of a therapy session (mood/medication/ other treatments check, setting initial agenda, obtaining an update and reviewing the Action Plan, discussing agenda items, periodic summaries, summary of session, final review of new Action Plan, and feedback)? You’ll see these session elements in the video of Session 10 with Abe (beckinstitute.org/CBTresources). You’ll learn about typical problems that arise in structuring sessions in Chapter 11. CONTENT OF SESSIONS The content of sessions varies according to the client’s issues and goals and your therapeutic objectives. When planning an individual session, you’re mindful of the stage of therapy and you continue to use your conceptualization of the client to guide treatment. As clients report on their mood, briefly review the week, and specify agenda topics, think STRUCTURING SESSIONS
about how to integrate your therapeutic objectives with your client’s agenda items. For example, in Session 5, my plan was to continue teaching Abe (though not necessarily all depressed clients) to evaluate his automatic thoughts and to continue to schedule activities. We also addressed the goals he put on the agenda. If you’re new to CBT, you may have time to discuss only one or two issues or goals in depth during a session. Experienced therapists can often cover more. See Figure 10.1 for Session Notes from my fifth treatment session with Abe. It’s important to take notes during the therapy session • to keep track of what is being covered, • to refine your conceptualization, and • to plan future sessions. As you take notes, maintain eye contact as much as possible. It’s important at times, especially when clients are revealing emotionally painful material, not to take notes so you can be more fully present with the client. Format of a Typical Session Figure 10.2 lists the parts of sessions. It’s helpful to provide rationales for each part in the first couple of therapy sessions. It’s also important to make periodic summaries throughout each session. In the initial stage of treatment, you’ll continue to socialize clients to CBT: following the session format, working collaboratively, providing feedback, and starting to view ongoing (and often past) experience in light of the cognitive model. If clients are feeling somewhat better, you’ll also start relapse prevention (Chapter 21). Above all, you’re concerned with inspiring hope, strengthening or maintaining the therapeutic alliance, and helping clients feel better and become more functional. THE FIRST PART OF THE SESSION The specific objectives of the introductory part of the session, described below, are to • reestablish rapport, • collect data to find out what issues/goals will be important to cover in the session, and • draw conclusions about what the client accomplished as a follow-up to the previous session.
Structuring Sessions
FIGURE 10.1. Session Notes. Copyright © 2018 CBT Worksheet Packet. Beck Institute for Cognitive Behavior Therapy, Philadelphia, Pennsylvania. Preparatory Notes: Continue activity scheduling and evaluating automatic thoughts; check on credit list. PATIENT’S NAME: Abe K.
DATE: 6/10
SESSION# 5
DIAG./CPT CODE: F 32.3
MOOD RATING/OBJECTIVE MEASURES (SPECIFY): Feeling “a little better.” PHQ-9 = 15; GAD-9 = 6; Well-being = 3. MEDS/changes/side effects/other treatment: None. RISK ASSESSMENT—suicidal/self-harm/homicidal ideation: No longer has thoughts of death; low risk. UPDATE/ACTION PLAN REVIEW/CONCLUSIONS DRAWN: Got more done in apartment/changing thinking and behavior affects mood/shows taking more control; out of apartment every day/sees he’s starting to take a “little more control”; felt best at concert/shows he values family/worth it to push self; read therapy notes daily; got out daily; babysat for granddaughters; dinner with son and family/good to get out/good to be with them/deserves credit; identified ATs; gave self credit. AGENDA ITEMS: “Hard stuff” in apartment, volunteering/tiredness, working for Charlie, evaluate automatic thoughts, schedule activities. AGENDA ITEM 1—PROBLEM OR GOAL: Working for Charlie CONCEPTUALIZATION—automatic thoughts/(meaning/beliefs, if identified)/ emotions/behaviors: Situation: Thinking about working a full day → AT: “I don’t have the stamina.” → Emotion: “Worried” → Behavior: Avoided calling Charlie back. INTERVENTIONS OR THERAPIST SUMMARY: (1) Taught the “What makes me think . . . ?” question to evaluate “I don’t have the stamina . . . ”; (2) Significant evidence AT is true; (3) Evaluated options when talking to Charlie; (4) Role-played what to say to Charlie. ACTION PLAN: Ask Charlie to keep him in mind for future work. Remind self that stamina will improve as depression improves. AGENDA ITEM 2—PROBLEM OR GOAL: Sorting mail, paying bills, filling out forms CONCEPTUALIZATION—automatic thoughts/(meaning/beliefs, if identified)/ emotions/behaviors: Situation: Thinking about getting started → AT: “It’s too hard.” → Emotion: “Depressed” → Behavior: Avoided mail. INTERVENTIONS: (1) Skills training (divide mail in four categories); (2) Evaluated AT (Response: “I don’t have to do everything. The first step is just sorting. I should be able to do the sorting. If unsure, immediately put items in ‘unsure’ pile and discuss next session.”) Also discussed what to do with the piles next session; (continued) Cognitive Behavior Therapy: Basics and Beyond
(3) Covert rehearsal; (4) Imagine completing task; (5) Response to AT (“I should have done it sooner”): “The depression got in the way”; (6) Set alarm on phone for tomorrow morning. ACTION PLAN: Read relevant therapy notes, imagine completing task, sort mail for tomorrow morning. OTHER ACTION PLAN ITEMS: Keep credit list; get out of apartment every day; see family, take grandsons to baseball game; identify automatic thoughts and ask, “What makes me think this thought is true? What makes me think it’s untrue, or not completely true?” SUMMARY/CLIENT FEEDBACK: Feeling better linked to changed thinking, behavior, and giving self credit; importance of taking control; very likely to complete Action Plan. Feedback—“good.” THERAPIST’S SIGNATURE: Judith S. Beck, PhD
NOTES FOR NEXT SESSION: Discuss volunteering? Increasing stamina? Assess self-criticism; continue activity scheduling and teaching evaluation of automatic thoughts. FIGURE 10.1. (continued) FIGURE 10.2. Structure of sessions. Initial Part of Session 1. Conduct a mood/medication/other treatment check. 2. Set the agenda. 3. Ask for an update (positives and negatives), and review Action Plan from the previous week. 4. Prioritize the agenda. Middle Part of Session 5. Work on agenda item 1, summarize, make intervention(s), assess need for further interventions, and discuss Action Plan items. 6. Work on agenda items 2 and 3 (if time). End of Session 7. Summarize the session. 8. Review the Action Plan for the coming week. 9. Elicit feedback.
Structuring Sessions
To accomplish these objectives, you will (1) do a mood/medication check, (2) set an initial agenda, (3) ask for an update and review the Action Plan, and (4) prioritize the agenda. Experienced CBT therapists tend to interweave these four elements, but I’ve separated them in this chapter for clarity. You may find that the beginning of each session proceeds more quickly if you ask clients to review (mentally or in writing) the Preparing for Therapy Worksheet (Figure 10.3) prior to the session. You can keep these worksheets in the reception area or you can send them home with clients until they’re socialized to give you a concise report of the previous week without this prompt. Mood Check The brief mood check creates several opportunities: • You demonstrate your concern for how clients have been feeling in the past week. • You and they can monitor how they’ve been progressing over the course of treatment. • You can identify (and then reinforce or modify) their explanation for progress or lack thereof. • You can reinforce the cognitive model: that their thoughts and activities have influenced their mood. • You can check on suicidal ideation, hopelessness, or aggressive or homicidal impulses that will need to be addressed in the session, usually as the first agenda item. FIGURE 10.3. Preparing for Therapy Worksheet. Copyright © 2018 CBT Worksheet Packet. Beck Institute for Cognitive Behavior Therapy, Philadelphia, Pennsylvania. 1. What did we talk about last session that was important? How much do I believe my therapy notes? 2. What has my mood been like, compared to other weeks? 3. What positive experiences did I have this week? What did I learn? What do these experiences say about me? 4. What else happened this week that’s important for my therapist to know? 5. What are my goals for this session? Think of a brief title for each (e.g., connecting more with people, getting more done around the house, and concentrating better at work). 6. What did I do for my Action Plan? (If I didn’t do an item, what got in the way?) What did I learn? Cognitive Behavior Therapy: Basics and Beyond
According to clients’ diagnoses and symptomatology, you might also ask for additional information, for example, the number and severity of panic attacks, time spent doing rituals, binges, substance use, angry outbursts, self-harm, or aggressive or destructive behavior. Here’s how my fifth session with Abe begins. Judith: Hi, Abe. How are you? Abe: Okay (handing over the scales he filled out). Judith: Are you feeling about the same? Better? Worse? Abe: A little better. Well, there was one time this week when I felt much worse, but for the most part, it was better. Judith: When we set the agenda, I’d like you to tell me about that time. But I’m really glad you had another better week. (pause) What was your sense of well-being like? Abe: About a 3. Judith: It seems your mood has been improving, little by little. (pause) Does it seem that way to you, too? Abe: Yeah, I think so. Judith: (looking at his scales) It looks like you’re having a little more energy? And you’re enjoying things just a little more? Abe: Yeah, that’s right. It’s important to get clients’ attribution for an improved mood. We want to help them see that positive changes in their thinking and behavior are associated with feeling better. Judith: That’s good. Why do you think your mood improved this week? Abe: I guess I’ve been feeling a little more hopeful, like maybe therapy is helping. Judith: [subtly reinforcing the cognitive model] So you thought, “Maybe therapy is helping,” and that thought made you feel slightly more hopeful, less depressed? Abe: Yes . . . and I got a fair amount done in my apartment this week. And spent time with my kids. Judith: Okay, so changing your thinking and changing your behavior is really affecting your mood. Abe: Yeah, I think so. Judith: Do you want to continue doing those things this week? Abe: I do.
Structuring Sessions
Next, I help Abe draw some positive conclusions about his behavior. Judith: What does it mean that you were able to do these things? You weren’t able to a few weeks ago. Abe: I guess that I’m taking more control. Judith: [providing positive reinforcement] Absolutely. CLINICAL TIPS • Sometimes clients are unsure as to why they’re feeling better. If so, ask, “Have you noticed any changes in your thinking or in what you’ve been doing?” • If there’s a discrepancy between clients’ narrative description of their mood from the past week and the scales they filled out, you might say, “So you’ve been feeling worse, but the score on this depression questionnaire is actually lower than last week. What do you make of that?” Three common difficulties can arise during the mood check (you’ll read about them in the next chapter): when clients attribute positive changes in their mood to external factors, when clients give too detailed a description of their mood, and when clients have experienced a worsening in mood. Medication/Other Treatments Check We covered the medication check previously (pp. 90–91). As a reminder, when relevant, you’ll ask about clients’ adherence to their prescribed medication (and difficulty with side effects) and other treatments. And when relevant, you’ll help clients create a list of questions for their prescriber. Setting an Initial Agenda The purpose of this relatively brief segment is to set an initial agenda. Here’s what to do: • Ask clients for their goal(s) for the session and find out (either next or when you prioritize the agenda) if there’s anything even more important to discuss. (Note: In traditional CBT, we’d be more apt to start by asking, “What problems do you want my help in solving?” or “What do you want to work on today?”) Cognitive Behavior Therapy: Basics and Beyond
• Gently interrupt clients when needed to label the goal or issue, instead of describing it at length. • Check your notes from the previous session and inquire about items you didn’t have time to cover. • Propose topics you’d like to cover. Throughout the first part of the session, you should also • ask whether clients anticipate any other important issues in the coming week, and • be alert for other important agenda items, such as negative experiences from the past week that are likely to recur in the coming week. Toward the end of the initial part of the session, you’ll also help the client prioritize topics to cover in the rest of the session. Judith: Let’s set the agenda, if that’s okay, so we can figure out what’s most important to you to talk about. What’s your goal for today’s session? Abe: Well, I’ve made some headway in my apartment, but there’s still a lot to do to clean it up. Some of the stuff is really hard and . . . Judith: (gently interrupting) Okay (writing down the goal), “Cleaning hard stuff in the apartment.” Anything else? Abe: I’m wondering if I’m in good enough shape to go volunteer again . . . I don’t know; I’m pretty tired [potential obstacle] and . . . Judith: (gently interrupting) Would you like to discuss that, too? (pause) Abe: Yeah, if we have time. Judith: Okay, “Volunteering and tiredness.” Anything else? Abe: Nothing I can think of right now. Rather than having Abe provide a full description of these topics, I lightly interrupt and name the goal/issue. Had I allowed him to provide a lengthy description of these issues, I would have deprived him of the opportunity to reflect on what he most wanted to talk about during the session—which may or may not have been the first issue he brought up. I also probe for additional agenda topics.
Structuring Sessions
Judith: You mentioned that you felt much worse one time this week. Is that something we should talk about? Abe: I’m not sure. I got this bad phone call from my ex-wife. She was yelling at me for still being out of work so I can’t pay her any more alimony. I felt really bad for a while. But that was the day I took my granddaughters to a concert, and by the time I got back, I felt better. Judith: Should we put your ex-wife on the agenda? Abe: Yeah, at some point, but not today, I don’t think. She probably won’t call me again for another couple of months. Judith: Okay, is there anything coming up this week that I should know? Abe: (Thinks.) Oh, yeah. My friend, Charlie, said he had some construction work for me. But I don’t know if I’m up for it. Judith: Should we look at the advantages and disadvantages of doing work for him? Abe: Yeah, that would be good. For clients who have difficulty figuring out what they want to put on the agenda, see pages 200–203. Next, I propose my agenda topics. Judith: And along the way, I’d like to tell you some more about evaluating your thoughts and scheduling activities again—if that’s okay. Abe: Okay. Update and Action Plan Review Next, you draw a bridge between the previous session and the current one. Often, you’ll combine a review of the Action Plan with the update. You’ll continue to remain alert for issues or goals that could be important for the agenda. Traditionally, we started the update by asking clients, “What happened in the past week that’s important for me to know?” When you ask that question, particularly toward the beginning of treatment, you’ll find that clients usually report negative experiences. If so, it’s important to ask them about positive experiences or times when they felt even a little better. In a recovery orientation, we tend to start with the positive by asking a question (or questions) such as: “What happened this week that was good?” “What did you do this week that was good?” Cognitive Behavior Therapy: Basics and Beyond
“When were you at your best this week?” “What was the best part of the week?” Emphasizing the positive helps clients see reality more clearly, as the depression has undoubtedly led them to focus almost exclusively on the negative. It helps them recognize that they didn’t feel the same unrelenting severity of distress for the entire week. Naming positive experiences also gives you the opportunity • to praise clients for engaging in meaningful social, productive, pleasurable, or self-care activities; • to help clients draw helpful conclusions about the activities, including the positive things they indicate about the client; • to evoke positive emotion in the session, putting clients in a better frame of mind and making them more receptive in the remainder of the session; • to discuss whether the client thinks it’s a good idea to engage in similar activities in the coming week; and • to strengthen the therapeutic relationship by becoming briefly conversational, perhaps using some self-disclosure. Judith: When were you at your best this week? Abe: (Thinks.) When I saw my granddaughters. I took them to a kids’ concert. They really like this singer—I forget his name; he plays the guitar and sings kids’ songs. Judith: [using self-disclosure to strengthen the therapeutic bond] I remember taking my own kids to events like that. I really should look into taking my grandchildren to a concert. Abe: I think this guy has another concert this coming weekend. Judith: Oh, thanks. (pause) Was taking your grandchildren out unusual for you? Abe: Yeah, I used to do it, but I haven’t done something like that for a long time. Judith: [eliciting positive conclusions] What was good about the experience? Abe: They were just really excited. And they were really happy I took them. Judith: Well, I’m glad you were able to do that. (pause) What did you learn?
Structuring Sessions
Abe: I guess that it was worth it to push myself. I was really tired and I didn’t feel like going, but I didn’t want to let them down. I should be doing things like this more often. Judith: That’s good. [trying to elicit an adaptive core belief] And what does it say about you that even though you’re so depressed and tired, you were able to get yourself to go? Abe: I’m not sure. Judith: Does it show that you really value your family, that you were willing to push yourself, that maybe you can take more control of your mood than you thought? Abe: I guess that’s right. Judith: Were there any other good things that happened this week? Abe: That was the best thing. I also got a lot done on my Action Plan. Judith: Good. We’ll get to that in a minute. Take note of the positive data. You may use this information later in the session or in future sessions, especially when planning positive activities for clients to engage in or when helping them evaluate relevant automatic thoughts and beliefs. Next, ask about other parts of the client’s week. Judith: Did anything else happen this week that’s important for me to know? Abe: (Thinks.) Umm. (Sighs.) Yeah, I think my younger brother is annoyed with me because I told him I didn’t think it was a good idea for him to leave his job. Judith: [probing to see whether it is important enough to add to the agenda] Is that something we should talk about today? Abe: No, I don’t think so. It’ll blow over. Judith: Okay, anything else? Abe: Not that I can think of. Judith: Anything coming up this week I should know? Abe: Just what I said before, you know, about Charlie, and maybe volunteering. Judith: Okay. Next, you’ll continue to find out what clients accomplished on their Action Plans. Judith: Can we talk about your Action Plan? Do you have it with you? Abe: Yeah. (Pulls it out; Judith pulls out her copy too.) Cognitive Behavior Therapy: Basics and Beyond
Judith: Were you able to read your therapy notes twice a day? Abe: Maybe 90% of the time. Judith: That’s good. Next, I ask Abe to read his therapy notes aloud and tell me how much he agrees with them. Then I check to see if he gave himself positive reinforcement, and we continue with the Action Plan review. Judith: Did you give yourself credit when you read the therapy notes? Abe: Yeah. Judith: Good. (looking at the Action Plan) Let’s see, did you get out every day? Abe: Uh, huh. I also went to my daughter’s house and babysat Saturday night. Judith: Did your daughter appreciate that? Abe: Yeah, and her husband too. Their babysitter cancelled at the last minute. Judith: Might this be something you could offer to do again? Abe: Yeah, I probably should. Judith: Should we put that on your Action Plan? Abe: Maybe put it as optional. Judith: Okay. (pause) And did you give yourself credit? Abe: Yeah. It was good I did it. It helped them out, and it was better than just sitting around with nothing to do at home. We continue to review Abe’s Action Plan. I give him positive reinforcement, ask about the meaning of his positive experiences, and discuss whether to continue a given Action Plan item in the coming week. He commits to continuing to get out of his apartment daily. During our discussion, I’m also alert for new agenda items that might take priority over the goals and issues we have already identified. Prioritizing the Agenda Next, you’ll list the issues or goals on the agenda. If there are too many items, you and the client will collaboratively prioritize them and agree to move the discussion of less important items to a future session. You may also find out whether clients want to spend about an equal amount of time on each item or primarily talk about one agenda topic.
Structuring Sessions
Judith: Okay, can we prioritize the agenda now? You mentioned you have a goal to do hard stuff in your apartment, maybe to do some work for Charlie, and to decide whether to volunteer even though you’re tired. Which one do you want to start with? Abe: Charlie. Judith: Good. (pause) Should we definitely leave time to talk about getting stuff done and the volunteering? Abe: Definitely about getting stuff done at home. It’s okay if we don’t get to talk about volunteering this week. Judith: Should we divide the time about 50-50 between Charlie and your apartment? Abe: That sounds fine. THE MIDDLE PART OF THE SESSION Next, you’ll work on the issue or goal that is of greatest importance to the client. At times, though, you may take the lead in suggesting the agenda item to start with, especially when you judge that a particular issue should take precedence: “Is it okay with you if we start with ?” In traditional CBT, you usually collect data about a problem that has already occurred and conceptualize the client’s difficulties according to the cognitive model. In a recovery-oriented approach, you’re more likely to ask clients what steps they want to take in the coming week toward achieving a goal (the flip side of a problem), and you’ll use the cognitive model to conceptualize obstacles that could get in the way of taking these steps (Beck et al., in press). In both approaches, you’ll collaboratively decide on which part of the cognitive model you will begin working on • the situation that has already occurred or a potential obstacle to taking steps toward a goal, • the automatic thoughts associated with the situation/ obstacle, and/or • the reaction (emotional, behavioral, physiological) associated with the automatic thoughts. You’ll choose an intervention, provide a rationale, elicit the client’s agreement, implement the intervention, and measure its effectiveness. In the context of discussing either issues or goals on the agenda, you’ll Cognitive Behavior Therapy: Basics and Beyond
be teaching clients skills and setting new Action Plans. You will also make periodic summaries to help you and the client recall what you’ve been doing in this part of the session. In discussing the first issue (and subsequent issues), you will interweave your therapy objectives as appropriate. Abe and I first discuss whether he should take Charlie up on his offer of doing some construction work. I ask Abe about his concerns. His automatic thought is “I won’t have enough stamina for a full workday.” I teach him two questions to evaluate his thinking: “What makes me think this thought is true? What makes me think it isn’t true, or not completely true?” The evaluation showed that Abe was probably right. We discuss his options: asking Charlie either if he could work for half a day or if he could keep Abe in mind for a future construction job. Abe chooses the latter option, and we role-play what he can tell Charlie. Then we discuss Abe’s second goal and proceed in the same way. It turns out that the “hard stuff” was mostly about sorting a large pile of mail, paying bills, and completing insurance forms. To address the obstacles that could get in the way in the coming week, we follow these steps:
- I collect data about the problem and ask Abe what thoughts he believes might interfere with doing these tasks.
- I summarize his difficulty in the form of the cognitive model, evaluate his automatic thoughts, and record good responses to them.
- We do problem solving (decided to just sort mail this week) and skills training (sorting mail into four piles).
- We collaboratively set an Action Plan item.
- We agree that Abe will set a timer, as we’re sitting in the office, to remind him to start the mail the next morning.
- We do covert rehearsal because Abe is still uncertain that he’ll be able to get started on the task.
- I ask Abe to imagine having completed the task. Judith: Abe, can you imagine that it’s tomorrow, just before lunch? You’ve been brave, tackling the stack of mail and you finished it. You’re sitting at the dining room table, looking at the four piles you’ve sorted the mail into: the “keep” pile, the “do-something- with” pile, the “throw-away” pile, and the “not-sure-what-to-do” pile. (pause) How are you feeling as you’re sitting there? Abe: Relieved. Nervous about the “do-something-with” pile and the
Structuring Sessions
unsure pile, but you said we could talk more about them next week. Judith: What are you saying to give yourself credit? Abe: That it’s good I finally did it. Judith: Are you proud of yourself? Abe: Yes . . . but I should have done it sooner [automatic thought]. Judith: How would you like to answer that thought? Abe: Like you said. The depression has gotten in the way. Judith: Exactly. What does it say about you that even though you’re still really depressed, you got yourself to sort the mail? Abe: I guess that I can do some things that I thought I couldn’t. Judith: Oh, that’s so important. Can we write that down for your therapy notes? Periodic Summaries You’ll summarize in three ways throughout sessions. One way is with the content. Clients often describe an issue with many details. You’ll summarize what they’ve said in the form of the cognitive model to make sure you’ve correctly identified what is most important to them and to present it in a way that is clearer and more concise. You’ll use your clients’ own words as much as possible, both to convey accurate understanding and to keep the key difficulty or goal activated in their mind: “Let me make sure I understand, Abe. When you thought about sorting the mail this week, you thought, ‘I can’t face doing this,’ and you felt really down and so you’ve been avoiding this job. (pause) Is that right? (pause) Did you feel any other emotion or have any other automatic thoughts?” I summarize using Abe’s actual words. If I had paraphrased, I might have done so incorrectly and probably reduced the intensity of the automatic thought and emotion. Then our subsequent evaluation of the thought might have been less effective. And when you substitute your words, clients may perceive that they haven’t been accurately understood. You’ll often ask clients to make a second kind of summary after you’ve finished discussing an issue or goal, to check on their understanding and reinforce important learning—for example: “Can you summarize what we just talked about? [or ‘What do you want to be sure to remember?’]” Cognitive Behavior Therapy: Basics and Beyond
When clients do a good job of summarizing, you or they should record this summary so they can read it daily as part of their Action Plan. You’ll make a third kind of summary when you’ve finished a section of a session, so clients have a clear understanding of what has just been accomplished and what comes next: “Okay, so far we’ve talked about and . Next, should we talk about ?” FINAL SUMMARY, CHECK ON ACTION PLAN, AND FEEDBACK Final Summary The goal of the final summary is to focus the client’s attention on the most important points of the session in a positive way. You also see whether there seems to be any problem with fulfilling the Action Plan. In early sessions, you’ll generally be the one to summarize. Judith: Well, we have just a few minutes left. I’d like to summarize what we covered today, and then I’ll ask you for your reaction to the session. Abe: Okay. Judith: It sounds like you felt a little better this week, and it seems to be due to reading your therapy notes, recognizing that some of your depressed thinking isn’t true, being more active, and giving yourself credit. You did a lot of things to take control of your life and your activities and your mood. You’re also starting to question your automatic thoughts and not immediately buy into them. (pause) Is that right? Abe: Yeah. Judith: Anything else to add to that? Abe: No, I don’t think so. CLINICAL TIPS As clients progress, you may ask them to summarize the most important points. Summarizing is much more easily accomplished if the client has recorded good notes during the session. You might say, “We just have a few minutes left.” Then you can ask: “What did you think was most important about today’s session?” or “What do you think is going to be most important for you to remember this week? You can look at your notes.” “What did you learn?”
Structuring Sessions
Check on Action Plan Next, I review what we discussed Abe would do before our next session. First, I list items he has already been working on for the past few weeks. But we’ve added a couple more items at this session, and I want to make sure he’s highly likely to do them and doesn’t feel overwhelmed. Judith: Okay, can we look at your Action Plan? How likely are you, every day, to read your therapy notes, get out of your apartment, and keep your credit list? Abe: 100%. Judith: How about talking to Charlie? That’s a onetime thing. Abe: 100%. I will. Judith: Sorting the mail? You can do it all at once or spread it out. Abe: I think I can do it. Judith: If you’re not sure, should we make it optional? Or set a time limit on it, say, 10 minutes? Abe: No, no, I’ll do it. Judith: And get tickets and take your grandsons to a baseball game? That’s another onetime thing. Abe: Yeah, I will. Judith: 100%? Abe: Yes. Judith: And finally, when you recognize an automatic thought, how likely are you to ask yourself, “What makes me think this thought is true?” And also “What makes me think this thought is not true, or not completely true.” Abe: I can do that. The rubber band will remind me. Judith: Does this all seem like too much to do? Abe: (Thinks.) No, I’ve already been doing a lot of it. Feedback Following the final summary, you’ll elicit feedback. By this time in our treatment, I was pretty sure that Abe would give me negative feedback if he had any. So I ask just one question: “What did you think about the session today?” For the first few sessions, I added these questions: “Was there anything I said that bothered you?”; “Anything you think I got wrong?”; “Anything you want to do differently next time?” Abe Cognitive Behavior Therapy: Basics and Beyond
- Conduct a mood check (0–10).
- Set an initial agenda.
- Request an update and review the Action Plan from the previous week.
- Discuss agenda item 1.
- Ask client to summarize what you discussed and write down therapy notes.
- Collaboratively set additional items for the Action Plan, if relevant.
- Elicit a final summary and feedback.
Structuring Sessions
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