SOWK6190/SOWK6127
Cognitive Behavioural Therapy and Cognitive Behavioural Intervention
Week 4 - Session two and beyond and the problems
with structuring the therapy session
Dr. Paul Wong, D.Psyc.(Clinical)
Outline
Review of homework
Recap of what we have learn
This week’s agenda
In-class activities
Homework
Typical agenda for session 2 and beyond
1. Brief update and check on mood
2. Bridge from previous session
3. Setting the agenda
4. Review of homework
5. Discussion of issues on the agenda, setting
new homework, and periodic summaries
6. Final summary and feedback
Goal of 2nd session
Help the patient select a problem or goal to focus on;
To start solving problems;
To reinforce the cognitive model and the identification of
automatic thoughts;
To continue socializing the patient into cognitive therapy:
following the session format, working collaboratively,
providing feedback to the therapist, and starting to view her
past and ongoing experience in light of the cognitive model.
Brief update and mood check
Key: elicits a subjective description from the patient and matches it with
objective test scores. Remember, if there are discrepancies, do ask explicitly.
“While I am looking at your test scores, tell me how your week went.”
“(if client mentions a problem/issue), Should we put this on the
agenda?”
“Anything else I should know about your week?”
Use any opportunity to “educate” your patient about the cognitive
model.
Why doing mood check again?
1) Demonstrate the therapist’s concerns for how the patient has been
feeling in the past week; 2) both the therapist and the patient can
monitor how the patient has been progressing over the course of
therapy; 3) identify the patient’s explanation for her progress or lack of
progress; and 4) reinforce the cognitive model.
Bridge from previous session
Key: to check on the patient’s perception and understanding of the
previous session that motivates the patient to prepare for the current
session by thinking about therapy during the week.
You can use the “Session bridging worksheet” (pp.49) to help the client
prepare for the next sessions.
“what did you get out of the last session? What was important?”
“Was there anything about last session that bothered you?”
If client forgets, then say, “what could you do this coming week so you’ll
remember what we talked about today?”
Note: a prime reason for patient’s failure to recall session content is the
therapist’s failure to encourage the patient to write down the important
points during the session itself.
Setting the agenda
Key: the therapist takes more responsibility for agenda setting
during early sessions and then gradually shifts responsibility to the
patient. It is important for the patient to learn agenda-setting skills so
she can contribute with self-therapy after termination.
“Okay, so we have already your exam and problem with roommate as
your current problems, we have also checked your mood, I’d like to go
through your homework and talk more about automatic thoughts.
Anything else would you like to set as an agenda for this session?”
“(if there are too many things on the agenda), What do you want to
focus on today?”
Note: if running out of time to go through everything from the agenda,
do make such a deviation explicit and elicits the patient's agreement.
Review of homework
Key: If the homework is not reviewed, the patient begins to believe that
it is not important and compliance with homework drops off
dramatically. Please do make sure you have the last session notes with
you as well!!!!!!!!!!
“what did you get done between the week?”
If the client did do the homework, ask why, and go through the
homework with her verbally.
For beginning therapist – it is easier to adhere to the explicit structure
and mark items to be discussed later.
Discussion of issues on the agenda, setting new
homework, and periodic summaries
Key: since the therapist and the patient develop the agenda together, it
is good to ask the patient which item on the agenda she wants to talk
about first. This affords the patient the opportunity to be more active
and assertive and allows her to take more responsibility.
Remember – you are actually doing five things at a time: 1) relate the
topic to the patient’s goal; 2) reinforce the cognitive model; 3) continue
teaching your patient about automatic thought; 4) provide some
symptom relief through helping your client respond to her
anxious/depressed thoughts; and 5) as always, maintain and build
rapport though accurate understanding.
Please read pp.54-58 carefully to have a sense of how these are done
thoughtfully.
Feedback
Key: In early sessions, the therapist helps the patient to do
the summarizing. In later sessions, do ask the patient
herself to do it.
“we’ve just a few minutes left. Let me summarize what we
covered today, and then I’ll ask for your feedback to the
session.”
If something important comes up from the client, you can
say: “maybe we can talk about that more next week, okay?”
Session 3 and beyond
Key: Follow the similar structure as used in session two. By
there are two major shifts: 1) the patient will be taking more
responsibilities in later sessions; and 2) cognitive tasks
with shift from automatic thoughts to both automatic
thoughts and underlying beliefs.
Also, highly recommend that you use the “Therapy Notes”
(pp.61) to keep yourself informed about each client. Review
them before and fill them up after each session.
Problems with structuring the therapy
session
Problems
When the therapist becomes aware of a
problem, he first specifies it, then
conceptualizes why the problem arose, and
finally devises a solution that does not
disturb the therapeutic alliance.
3 Commonly occur problems
1. Socialization (in terms of therapeutic alliance
and CT)
2. Patient’s unwillingness to conform to the
prescribed structure because of her
perceptions of and dysfunctional beliefs about
herself, the therapist, and/or therapy.
3. Difficulty in maintaining the session structure
arises because the therapist has imposed the
structure in too controlling or demanding a
fashion.
Brief Update
• Patient begins the session with too details
an account of or unfocused rambling about
her week.
• T: “Let me interrupt you for a moment… I
need a big picture….”
• T: rephrase “it sounds like you had a hard
week….”
Mood Check
Patient’s failure to fill out forms, annoyance with forms, or
difficulty in subjectively expressing her general mood
during the week.
Solution – asks the patient whether she remembers and
agrees with the rationale for filling them out and determines
whether there’s a practical difficulty that needs to be
resolved.
Check automatic thoughts.
• T: “I know you see the forms as irrelevant, but
actually they save us time in the therapy session
because I don’t have to ask you lost of questions
myself”.
Bridge from Previous Session
Patient’s difficulty in remembering session content
because:
She is reluctant to do the homework; and the
therapist fails to encourage the patient to jot things
done during and after the session.
Setting the Agenda
Patient is inadequately socialized or puts a special
negative meaning on contributing to the treatment.
T: “What problems came up for you this past week/
Or what problems do you expect might come up
this week?”
T: “What went through your mind when I asked
you to set the agenda for the session?”
Setting new homework
Therapist:
1.Suggests an assignment that is too difficult or is unrelated to the
patient’s concerns;
2.Fails to provide a good rationale;
3.Forgets to review homework assigned during previous sessions;
4.Does not stress the importance of daily homework in general and of
specific assignments in particular;
5.Does not explicitly teach the patient how to do the assignment;
6.Does not start the assignment in session or ask standard questions
about potential obstacle that might get in the way;
7.does not have the patient write the homework assignment down; or
8.Non-collaboratively sets a homework assignment that the patient not
want to do.
Most importantly –
Your cognition and attitude about CBT
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“I can’t structure the session”
Patient won’t like the structure”
Patient can’t express herself succinctly”
“I shouldn’t interrupt her (that will damage the rapport)”
“She’ll get mad if I am too directive”.
Homework
Since you have some basic knowledge about CT/CBT now,
it’s time you can do some preliminary self-reflection about
your own attitude and belief about CBT.
Please answer this:
“Am I suitable to be a CBT therapist? If yes, why? If no,
why not?”
Do send your answers to me by e-mail. Don’t write an
essay, just something very brief is enough!!!