Did you have a chance to try setting goals with a new or current client? Did you try any other homework assignments from previous chapters? When you think of the interventions that you’ve tried, what would you like to continue doing?
If you did not have a chance to try setting goals, take a moment and identify what obstacles got in the way. Choose a specific client you will see this coming week who you think would be open to setting goals. Now imagine yourself in your office setting goals with this client, and then try it!
We have identified your client’s problems, taken a history, explained the CBT model, and set goals. This usually takes between one and two sessions. You are now ready to start addressing your client’s problems. In this chapter, I want to focus on how to structure or organize your therapy sessions.
Research shows that having a structure, and in particular setting an agenda, keeping to the agenda, and giving homework are key factors in effective therapy (Shaw et al., 1999). Many of my students tell me that structuring a session is one of the most helpful CBT skills that they learned; I think you will also find it helpful.
A structured session means that there is an order and organization to the therapy session. Here is a brief overview of the five basic components. I will go over each one in more detail later in the chapter.
At first, covering all of these components in one session may seem like a lot. However, once you get used to using a structure, it will flow naturally; my prediction is that you will wonder how you ever worked any other way. Learning to use a structure is similar to learning to drive a car. When I first learned to drive I was quite overwhelmed with how much I had to do all at once. I remember the first time I parked my parents’ car in the garage. I was so focused on not putting too much pressure on the gas, remembering where the brake was, and making sure that I did not hit anything on the right side that I scratched the whole left side of the car on the garage wall. I didn’t even have the necessary reflexes to hit the brake. With practice, driving became easy; and, you will be happy to know, I have not smashed into any walls in years! Just as driving is now a routine activity for me, using a structure will feel like the normal way of working once you have practiced with a few clients.
Some therapists immediately like the idea of a structured session; others have negative reactions such as I will find a structure too rigid, My clients won’t like it, and It will interrupt the flow of therapy. However, I believe that after you try structuring sessions with a few clients you will start to think, Structure gives my therapy more focus, and My clients will like having a chance to let me know what they want to focus on. Take a moment to notice your own thoughts about using a structure.
Explaining the structure of a therapy session will help your client feel more comfortable, as she will know what to expect. I think of therapy as similar to visiting a foreign country. If you don’t know the customs, and you don’t know what to expect, you will be uncomfortable. When I was in my twenties I spent a year in Indonesia. I remember the first time I went to an Indonesian wedding. I walked into the room, looked around, and had absolutely no idea what to do. To say the least, I felt very awkward. I can still remember my relief when my friend who had invited me took my arm, gently sat me down, and explained what was going to happen and what I needed to do. Explaining the structure of therapy is similar to explaining the customs of a foreign country. Your clients will be more relaxed and trusting if they know what to expect. You can find a Explain the Structure of a Therapy Session handout at http://www.newharbinger.com/38501.
We’ve spent some time getting an idea of your problems and setting goals for therapy. I want to explain how I’d like to structure the actual therapy sessions. Each week when you come in I want to start with a brief check-in so that you can bring me up to date on anything that has happened in your life since our last session and we can get a sense of how you are doing. Then I want to make a list of what you would like to talk about during our therapy session. I find this helps make our sessions more focused, and that way I can be sure that we talk about what is most important for you. I call this setting an agenda. Often you and I will have decided on some homework that you are going to try in between sessions. If you had any homework, I will check on how it went. At the end of the session, we’ll spend some time summarizing what we’ve covered and make sure that we are on the right track for you. We will also see if there is any homework that makes sense for you to try before our next session. How does that sound to you?
Most clients just say “Fine,” after which I say, “Let’s start. Could you bring me up to date on how your week has been and then we can see what you would like to focus on today?” With a new client, this is a straightforward process, and it almost always goes smoothly.
I’ve been thinking about our sessions, and I would like to try something new today. I thought we would start with a brief check-in, so that you can bring me up to date on anything that has happened in your life since our last session and we can get a sense of how you are doing. I would then like to make a list of what you would like to focus on during our therapy session today and decide which issue you would like to start with. I think this will help focus our sessions, and that way I can be sure that we talk about what is most important for you. At the end we’ll spend some time summarizing what we covered and see how you liked working this way.
Notice I am very clear about what we will do and that I will check whether my client likes this new way of working. My guess is that almost all of your clients will find having a structure helpful. Once you have explained setting a structure, it becomes a normal part of therapy. Clients who are used to the structure tend to spend time before the session thinking about what they want to talk about. Therapy becomes more focused; clients usually come in with one or two agenda items. When a client is used to a structured format, I start with, “Hello, good to see you. I want to check in and see how you have been doing, see what you would like to focus on today, and check how your homework went.”
I would like you to imagine explaining how a session is structured, first with a new client and then with a current client. Before you start this exercise, rate from 1 to 10 how comfortable you feel explaining structuring a session with both a new and a current client, with 1 being very comfortable and 10 being very uncomfortable. At the end of the exercise, rate your level of comfort again to see if it has changed. Now, let’s try the exercise.
The check-in is an opportunity to get a general sense of how your client is doing, find out if there have been any new developments in her life, and check on any issues that were raised in the last session. That way, if there have been any major events, or changes in your client’s life, you know about them right from the beginning of the session.
Below is a review of the main components of the check-in that are covered in most sessions. Depending on the flow of the session, you may not necessarily complete the components in the order below.
Let’s look at the different components.
Let me give you a quick example of how rating your client’s mood can be helpful. When I started working with Donald, his depression was at a 10 and we wondered whether he should be hospitalized. After about six months of therapy, Donald had significantly improved, and his moods were generally in the 4 to 5 range. He had been away and I had not seen him for over two weeks. He started his session saying he had been very depressed for the past two weeks, and he was scared that he would need to be hospitalized. He rated his overall mood at an 8. Realizing he was at an 8 and not a 10 helped him feel less frightened and enabled him to focus on the issues related to his increased depression.
If your client completed her homework, give positive feedback and indicate that it is important. Check what she actually did as well as the outcome. Clients don’t always understand the homework in the same way you intended it. You then want to ask what your client learned from doing the homework.
If your client did not complete the homework, explore what got in the way. I usually ask my client what might help her complete homework in the future. If possible, we spend some time completing the homework task in session. At the end of the session, I spend extra time making sure the homework for the coming week makes sense to my client. Later in this chapter we are going to talk about how to develop effective homework.
The challenge with the check-in is to keep it short and focused. This means that rather than immediately exploring an issue your client brings up, you need to contain the client and make sure this is what she wants to address in the therapy session. For example, imagine that during the check-in your client starts giving a long and complicated example of a difficulty she is having with her child’s teacher, and you have not yet set the agenda. You might say, “I think this is an important topic. However, before we talk more about it, I want to make sure this is what you want to focus on today and see whether there are any other issues.” If you have explained to your client that she will set the agenda at the beginning of the session, she will find it normal that you stop and check what she wants to talk about. She may say, “Yes, this is the main issue.” In that case, you have your agenda. The check-in is a balance between exploring issues enough to have some understanding of the issue and make sure there is no immediate crisis, and not letting the check-in take the whole session.
Here are some phrases that I have found helpful in keeping my client focused during the check-in:
When a client comes in and starts talking about an important situation in her life, it can be hard not to get pulled into starting therapy and forget about finishing the check-in or setting an agenda. You can be straightforward and simply say, “I just realized that we started talking about this issue, and I never asked if this is the main topic you want to talk about today.”
A word of caution: while CBT sessions follow a set structure, it is important to be flexible and sensitive to your client’s needs. For example, if a client starts a session by sobbing as she tells me about an awful event that just occurred, of course I would not rigidly keep to a structured session. I listen empathically, assess her immediate needs, and help her deal with her overwhelming emotions. However, after I have listened to what happened, if the client is calmer, I might say, “I want to talk more about this. But I also want to double-check whether there is anything else you want to talk about today.” I have often been surprised that even if my client is in the middle of a crisis, there may be additional issues she wants to address.
Let’s look at an example of how a check-in might work. This is Suzanne’s fourth session and her therapist has already explained using a structured session. Before reading the dialogue below, ask yourself: how would you start the session?
Therapist: Hello, good to see you. I would like to check in, see how your week has been, make a list of what you would like to focus on today, and hear how the homework went.
Suzanne: (looking downcast) Well, my week has been pretty much the same and pretty awful. I did the homework and have it here.
Suzanne’s therapist wants to follow up on the homework but also wants her to rate her mood and continue with the check-in.
Therapist: It’s great that you did the homework; I want to follow up on it, but first I want to get an overall sense of your week and check what we need to focus on today. Is that okay with you? (Suzanne nods.) I was wondering…if you were to rate your mood over the past week, where would you put it?
Note how the therapist redirects Suzanne to the tasks of the check-in.
Suzanne: Probably overall a 7; I just felt really down a lot of the time.
Therapist: So the same as last week. Were there any times that were particularly hard, or any times when your mood was better?
Suzanne: I’m not sure, I was pretty down most of the week. Home is still the same. I can’t stand the new school. I think the teachers are really awful. No matter how hard I try, I just don’t fit in. (Sounding more upset and agitated.) One of the teachers asked me what I do at lunch, since she never sees me in the lunchroom. I didn’t know what to say.
This could be a good issue to focus on in therapy as it relates to Suzanne’s goal of “trying to fit into the new school.” However, it is also not a crisis issue and other issues might be more important. Notice her therapist did not respond, “How did you feel when she asked you what you do at lunch?” or “Tell me more about that,” as these responses would encourage Suzanne to keep talking about that incident.
Therapist: Sounds like you were pretty upset by the teacher’s comment. Before we talk more about it, I want to check if that was the main thing you wanted to talk about or whether there were other issues.
Suzanne: That just happened this morning. I don’t really want to spend time on it; it’s not that important.
At this point in the check-in, Suzanne has indicated that there have not been any changes in her life and she has rated her overall mood. There is nothing the therapist wants to raise as a bridge from the last session. The next step is to discuss the homework and set an agenda.
Your Turn! Help Raoul Stay Focused During the Check-In
Let’s see how Raoul’s therapist uses the check-in.
Look at the three possible responses below. Choose the response that will help Raoul stay focused on checking in.
Response #3 keeps Raoul focused on the check-in and structure of therapy. His therapist is also demonstrating empathy about the urgency of the project. In response #1, the therapist tries to be supportive but assumes that this issue with the boss is the main agenda item and has not checked in or set an agenda. In response #2, the therapist starts to problem solve without being sure this is the topic Raoul wants to focus on.
In this situation you have an agenda item that came from the check-in. Before you start discussing the agenda item, you need to ask Raoul to rate his overall mood during the week, and check if there are any other issues he would like to talk about in therapy. All you need to say is, “Before we talk about your difficulties with the project, I want to do a quick check on how your overall mood has been this past week. How would you rate your mood, from 1 to 10?”
Setting an agenda involves collaborating with your client to make a list of what she wants to focus on in the session. Some therapists think that setting an agenda sounds like a business meeting, but it is actually very client focused. When you set an agenda you are saying, “I care that our therapy focuses on what is important to you, so at the beginning of our session I want to spend a few minutes checking on what you want to talk about.” The process involves the client expressing her needs, and you, the therapist, hearing and responding to her needs. This can be very empowering for your client.
Setting an agenda also sets the expectation that therapy is not just about coming and talking; you expect your client to work on specific problems and to give some thought to what she wants to talk about. You, the therapist, can also add issues to the agenda. For example, if you talked with a teenager’s probation officer or parent, this would be a good time to let the teen know and add it to the agenda. It is helpful to write out the agenda and place it where you and your client can both see it. Many therapists have a white board or flip chart in their office, but you can also use a piece of paper.
One of the many things I like about setting agendas is that it helps with what I call “doorknob therapy.” Doorknob therapy is when you have finished the session and your client has a hand on the doorknob, ready to leave, and says, “Oh I forgot, I wanted to talk to you about this really important issue.” You can then say, “That sounds like an important issue. Can we put it on the agenda for next time, and start with it?” If your client regularly raises important issues at the end of therapy, you can start therapy by saying, “The last couple of sessions it wasn’t until the end that you remembered an important issue you wanted to talk about. I thought it might be helpful to take a moment and think about what you want to talk about today.” As your client learns to set an agenda for her therapy session, she is taking responsibility not only for her therapy, but also for making changes in her life.
Once you have a list of agenda items, the next step is to ask the client which issue she would like to start with. If a client has a large number of issues on the agenda, I simply say, “There are too many issues for us to talk about all of them today. Let’s choose two or three and see if we can start to work on them.” It can also be helpful to decide roughly on the amount of time you will spend on each issue. At about the midpoint of the session I usually let my client know the time and ask whether she wants to stay on the issue we are discussing or move to the next issue on the agenda.
Below are some helpful questions for setting an agenda. You can download a Questions to Help Set an Agenda handout at http://www.newharbinger.com/38501.
Let’s look at how Suzanne’s therapist sets the agenda after they finished the check-in. If you remember, in Suzanne’s case there were no agenda items that came from the check-in.
Therapist: I want to spend a few minutes making a list of what you would like to focus on today. I also want to be sure we spend some time going over the homework, but I want to check whether there is anything else you want to bring up.
Suzanne: Actually, the main issue I want to talk about is that I got an invitation from the principal to a barbecue for new teachers at his home. I’m really anxious, and not sure if I should go.
Therapist: That sounds like an important issue. Anything else you want to talk about?
Suzanne: Actually, yes, I have been really angry with my husband this past week. He promised to take care of the kids on the weekend and ended up working. Those are the two big ones I want to talk about.
Both issues relate to Suzanne’s goals. It is just a question of which is more important to her.
Therapist: Between the barbecue and being angry with your husband, where would you like to start?
Suzanne: I think the barbecue, as I’ve been really worried about it. The issue with my husband doesn’t feel as urgent.
Therapist: Would it be okay if we start with looking at the homework, then spend some time talking about the invitation to the barbecue, and if we have time, finish with looking at how angry you have been with your husband?
Suzanne: That sounds good.
Raoul had identified an agenda item in the check-in. His therapist wants to check whether there are additional issues he wants to talk about in session.
Therapist: I would like to make a list of what we want to focus on today. One issue that you identified is the project that is due; is there anything else you would like to talk about today?
Raoul: Actually, my wife wants to invite her sister to stay with us for a month while she looks for a new job. I’m really upset—what if it takes her sister a really long time to find a job? We can’t just let her move in, but we can’t say no, she’s family. Her sister is a very difficult woman who talks all the time. She expects us to just take care of her.
Therapist: Sounds like it would be important to talk about your wife’s sister maybe moving in, too. I just want to check if there is anything else.
Notice how the therapist summarizes the problem to indicate she heard Raoul’s concern, but then sticks to setting the agenda.
Raoul: Those are the two. I have to say, the idea of my sister-in-law living with us is not great. She’s pretty critical, and I don’t think she really likes me. She also puts my wife down all the time.
It is tempting to start talking about the sister-in-law; however, we have not asked Raoul where he would like to start.
Therapist: We have two big issues; which one would you like to start with, the project at work or your sister-in-law?
Raoul: I think the project, because if I don’t get this project done, I risk another bad work evaluation! It’s just all so much.
Therapist: It is a lot. How about if we started with the project? I’ll let you know when we are halfway through the session and then we can talk about your sister-in-law.
Notice how the therapist sticks to the structure but adds the empathic comment “It is a lot” to indicate that she heard Raoul’s distress.
Once you have set an agenda and decided on the first item, the next step is to start working on that issue in therapy. One of the challenges is sticking to an agenda item. In my experience, therapy drifts. For example, a client may start talking about her anger toward her father, who criticized her parenting, and drift to talking about her feelings toward her cousin who is moving away. It is easy to stray from the agenda. When you talk with a friend, you drift from topic to topic; however, in therapy you want to focus on a specific problem.
The easiest way to keep your client focused is to point out that she has strayed from the agenda and ask her what she would like to do. You can gently say, “We were talking about your feelings toward your father, and we’ve moved to talking about your cousin. I am wondering if you want to go back to discussing your father, or if this issue with your cousin is more important.” That way, you give your client a choice. However, it is important to be flexible. If your client starts to talk about a painful issue that has been difficult for her to discuss or discloses a traumatic or very distressing event, you follow your client’s lead.
Homework is an opportunity for your client to practice in her everyday life what she worked on in therapy. In a meta-analytic study, Kazantzis, Whittington, and Dattilio (2010) found that overall, 62 percent of clients improved when therapy included homework, compared with 38 percent of clients who improved when therapy did not include homework. This seems to me like a pretty compelling reason to include homework in your therapy.
Homework can take many forms. Some examples might be noticing the situations where your client has specific difficulties, asking your client to complete a thought record, or asking your client to try a new behavior.
Clients who complete homework tend to benefit more from therapy (Rees et al., 2005). So, how do you increase the chances that your client will complete her homework? First, be sure to leave between five and ten minutes at the end of the session to plan the homework. Assignments given in a rushed manner tend not to get done. Second, use the following four criteria to develop helpful homework. You can download a Guidelines for Helpful Homework handout at http://www.newharbinger.com/38501.
Unless homework is specific and concrete, it is impossible for your client to accurately evaluate whether she completed the homework. For example, Raoul’s homework was to start work on a group project he had been avoiding. The next session Raoul reported that he contacted his colleagues and set up a meeting for next Tuesday. Raoul added, “I wasn’t able to do the homework; I should have already started the project.” If his homework had been to contact his colleagues and set up a meeting, might Raoul have had a different reaction?
Your Turn! Evaluate Suzanne’s Homework
In session 6 Suzanne talked about how she has stopped doing almost all of the activities she used to enjoy with her children. Suzanne had been very sad and self-critical during the session and often teary. With only a few minutes left in the session, Suzanne sighed sadly and said, “I have become a terrible mother. I would so like to go back to doing fun things with my children again.” Suzanne’s therapist responded with, “I would like to give you some homework. I think it would be really helpful if you could try to do some fun things with your children this coming week.” Does this homework meet the guidelines for helpful homework? Complete the chart below. You can find my answers in the appendix.
| Helpful Homework Guidelines | Does Suzanne’s Homework Meet This Guideline? |
|---|---|
|
The homework is developed collaboratively. |
|
|
The homework is specific and concrete. |
|
|
The homework is related to the session. |
|
|
The homework is doable. |
Before you look at the dialogue below, what questions could you ask Suzanne so that together you could develop homework that fits the guidelines?
It is important to start developing the homework when you have at least five minutes left in the session. Notice that the therapist first asks Suzanne whether she has any ideas.
If Suzanne could think of an activity, together they would make a specific plan that included when the activity could happen and specifically what Suzanne would do. The therapist would check that the plan felt doable and that Suzanne had everything she needed to do the homework. Lastly, the therapist would check if there were any obstacles.
Suzanne and her therapist decided she would sit with her children for ten minutes on the couch and watch TV with them before starting dinner. Suzanne would do this Monday and Wednesday evening this coming week. Is this homework collaborative, specific and concrete, related to the session, and doable? I think it is.
I don’t want my client to think that she failed if she does not do the homework or it does not go well. I often end our discussion about homework by saying, “If you do the homework, that is great and it will help us see how you can start moving toward your goals. If you don’t do the homework, it is important that we explore what happened, as this will give us some clues as to what is keeping you stuck in your problems.”
The last section of a structured session involves reviewing the session and asking for feedback. This section is often forgotten or rushed, but it is just as important as the other components.
One of the best ways to help your clients remember what was covered in therapy is to ask them to review. If they forgot to mention a point you think was important, you can raise it and ask if it also seems important to your client. Many of my clients keep notebooks and either during the session or at the end write down the points they want to remember. In my clinical notes, I also write down the main points from the review. Below are some helpful ways to introduce reviewing the therapy session. You can download a Questions to Review the Therapy Session handout at http://www.newharbinger.com/38501.
A few years ago I noticed that if I thought the session had not gone well, I would “forget” to review, or else I conveniently ran out of time. When I started reviewing even when I thought the session had not gone well, I discovered that a good part of the time my client had found the session helpful. This was very useful information. If my client had not found the session helpful, this was also valuable information. We now had a problem we could discuss and potentially solve rather than my worrying about the session.
After you review the session, it is a good time to ask for feedback. This is especially important in the beginning of the therapy relationship. I simply say, “I want to check if it feels that we are on the right track” or “I want to check if there was anything that we did that was particularly helpful for you. Was there anything that didn’t feel like a helpful use of our time?”
Your Turn! Practice in Your Imagination: Review a Session with Your Client
Choose a client you are currently seeing who you think would be open to reviewing the session. Before we begin, rate from 1 to 10 how comfortable you are with asking your client to review the session, with 1 being very comfortable and 10 being very uncomfortable. At the end of the exercise, rate your level of comfort again to see whether it has changed. Now, let’s try the exercise.
Imagine you are at the end of a session and you want to ask your client to review the session. Try to get a picture of him or her in your mind. Imagine yourself in your office. Take a moment to look around, notice the sounds and smells in the room. Read over Questions to Review the Therapy Session while imagining yourself asking the questions. You can also use your own phrases. Really hear and feel yourself introducing the idea of reviewing. Now imagine reviewing two more times with the same client. Each time imagine that your client responds positively.
Before continuing with the next chapter, take some time to try the homework.
Complete the following exercises.
Most of us wake up every morning and there is a long list of what we have to do. We have to prioritize and figure out what is most important to us, or we would never get anything done. Setting agendas in therapy is similar to figuring out what is most important to attend to in our own lives.
Homework Assignment #1 Use a Structure in Your Life
An agenda is a list to help your clients identify and prioritize what is most important to them. Many people make lists to help them organize their lives and figure out what needs to be done first. I thought it would be helpful for you to reflect on your own experience of making lists and identifying your priorities.
First, consider lists you’ve written in your life. Take a moment and think about a time when it was helpful to make a list, and a time when it was not helpful. Then identify factors that contributed to the list being helpful and factors that contributed to the list not being helpful.
Second, think about the next couple of days. Make a list of things you need to accomplish in the next few days that are not part of your normal routine. It can be either at work or in your personal life. After you’ve made the list, pick three items that are a priority to accomplish. Try to make them as concrete and specific as possible.
Third, think about this exercise and if there are any implications for how you can make agenda setting more helpful for your clients. Now take a moment to review what you learned.
I want to explore your expectations and any concerns you have about using a structured format.
Homework Assignment #2 Explore Your Attitudes about Using a Structured Format
Choose two clients whom you are currently working with. Imagine that with each client you set an agenda and review at the end of the session. I am going to ask you to write down your predictions.
Complete the following form for each client.
1. My client will:
| 1 | 2 | 3 | 4 | 5 |
|---|---|---|---|---|
|
Dislike using a structure |
Have a neutral reaction |
Like using a structure |
2. I will:
| 1 | 2 | 3 | 4 | 5 |
|---|---|---|---|---|
|
Dislike using a structure |
Have a neutral reaction |
Like using a structure |
3. What I imagined happening:
4. My main concern about using a structured format with this client is:
Homework Assignment #3 Structure a Session with a New and Current Client
Choose two clients with whom you are going to try and structure a session. If possible, choose one new client and one current client with whom you are not using a structured session. You are more likely to learn a new skill if you practice the different components individually before you put it all together. I want you to start by only practicing three components of a structured session: (1) explain the structure of a therapy session, (2) set an agenda, and (3) choose an agenda item to focus on. Here are the three steps:
If you are setting an agenda with a current client, at the end of the session ask if your client liked setting an agenda. You can say, “I am curious whether you liked the structure we used today where we made a list of what you wanted to work on.” If your client had a positive reaction, ask if she would like to continue using this structure in the future.
After you try setting an agenda for the first time, notice if your predictions about your own and your client’s reactions were accurate. Take a moment to think about what you learned. Have your predictions changed?
Homework Assignment #4 Review the Session with Your Client
Once you have tried setting an agenda with two clients, I would like you to include one more component of a structured session.
At the end of the session, ask your client to review the session. Remember, all you have to do is ask, “When you look over our work today, what would you like to remember?” As you did in the last exercise, notice if your predictions of your own and your client’s reactions were accurate.
Answer the questions under the agenda items.