COGNITIVE BEHAVIOR THERAPY
A: You will decide whether to try other techniques (see Chapter 9), or whether to return to this task in the next session. Common sense
Structure of the First Therapy Session 73 paTienT: That sounds hard.
TherapisT: That’s another good example of an automatic thought:
“That sounds hard.” Well, that’s what I’m here for. We’ll be working as a team, together, to help you solve your problems, and we’ll go step by step. (pause) Can you see how changing your thinking and doing some problem solving might help improve your mood?
paTienT: Yes.
TherapisT: (Using an encouraging tone of voice.) And I think you’ll find that you’ll get good at it pretty soon. Meanwhile, can you try to write down other depressed thoughts like that so we can look at them next session?
paTienT: Okay.
TherapisT: [checking to see whether Sally anticipates difficulties that might require advance problem solving] Do you think you’ll have any trouble doing that?
paTienT: No. I think I’ll be able to.
TherapisT: Good. But even if you can’t, that’s okay. You’ll come back next week and we’ll work on it together.
paTienT: Okay.
In this section, I explain, illustrate, and record the cognitive model with the patient’s own examples. I try to limit my explanations to just a couple of sentences at a time; depressed patients, in particular, have difficulty concentrating. I also ask Sally to put what I’ve said in her own words so I can check on her understanding. Had Sally’s cognitive abilities been impaired or limited, I might have used more concrete learning aids such as faces with various expressions to illustrate emotions, and car- toon characters with empty “thought bubbles” above their heads.
Q: What if . . . patients have difficulty grasping the cognitive model in the first session?
A: You will decide whether to try other techniques (see Chapter 9), or
DISCUSSION Of PROBlEm OR BEHAVIORAl ACTIVATION
If there is time in this first session, you will start discussing a specific problem of significant concern to the patient. Developing alternate ways of viewing the problem, or concrete steps patients can take to solve the problem, tends to increase their hopefulness that treatment will be effec- tive. Unless patients express a problem of overriding importance, try to elicit their agreement to discuss the problem of inactivity—that is, if they have withdrawn from activities or are generally at least somewhat inac- tive. Overcoming depressive passivity and creating opportunities to expe- rience pleasure and a sense of mastery is essential for most depressed patients. Behavioral activation is discussed in the next chapter.
END-Of-SESSION SUmmARY AND SETTING Of HOmEWORk
The final summary ties together the threads of the session and rein- forces important points. The summary also includes a review of what the patient has agreed to do for homework.
TherapisT: Sally, our time is almost up. Can you tell me what you think is most important for you to remember this week? You can look at your notes [page 67].
paTienT: Well, I guess that I’m not lazy. And I might have a lot of depressed thoughts that will make me feel bad, even if they’re not true.
TherapisT: Right. And how about the idea that getting more active might help improve your mood?
paTienT: Yes.
TherapisT: Can we go over the homework now? I want to make sure it’s doable. (pointing to the paper) The first thing we wrote down is to remind yourself that you’re depressed, so you won’t start thinking that you’re no good. Now, how will you remember to do that? Do you think you could read this sheet of paper when you get up every morning?
paTienT: Yeah.
TherapisT: How long do you think it will take you?
paTienT: I don’t know. Maybe 5 minutes?
TherapisT: Actually, I think it will take less than a minute.
paTienT: Yeah, that’s probably right.
Structure of the First Therapy Session 75 TherapisT: How will you remember to do it?
paTienT: (Thinks.) I’m not sure. I don’t want to keep it out because my roommate could see it.
TherapisT: [making specific suggestions] Could you keep the paper somewhere else, like in your backpack? Maybe you could set an alarm on your cell phone, so when it beeps, you’ll remember to get it out and read it?
paTienT: Yeah, that would work.
TherapisT: It would also be good to read it at least once more every day. When do you think it would help most?
paTienT: (Thinks.) Probably right after dinner.
TherapisT: That sounds good. Do you want to set an alarm for then, also?
paTienT: Okay.
TherapisT: I’ll write that plan at the top of the sheet.
Next, we add to the homework assignment sheet, noting aloud how long each task will probably take to accomplish. Many patients overesti- mate the difficulty and duration of tasks. Specifying time requirements help ease the perceived burden.
TherapisT: Sally, we also talked earlier in the session about adding to your goal list this week. Do you think you could spend a minute or two on it this week?
paTienT: Sure.
TherapisT: And finally, I have a booklet here about depression [Coping with Depression; see Appendix B]. Should we make it optional?
paTienT: (Nods.)
TherapisT: I think it will take about 5 or 10 minutes to read. If you do read it, you can make mental notes or written notes on what you agree with and what you don’t.
paTienT: Okay.
In this part of the session, I want to maximize the chance that Sally will do the homework and feel successful. If you sense that the patient may not carry out any part of the assignment, you may offer to change it (“Do you think you’ll have trouble jotting down your thoughts?” [If yes]
“Do you think we should make it optional?”). Depressed patients can easily become overwhelmed and then self-critical if they do not com- plete their homework assignments. (See Chapter 17 for an extended discussion of homework.)
We also discussed when it would be helpful for Sally to read this sheet of paper. It is important to note that Sally, accustomed to doing homework for school, is less likely to be overwhelmed and more likely to follow through with these activities than another depressed patient might be. Some patients may decide to transfer this written list to their smartphone or other electronic device.
fEEDBACk
The final element of every therapy session, at least initially, is feed- back. By the end of the first session, most patients feel positively about the therapist and the therapy. Eliciting feedback further strengthens rapport, providing the message that you care about what the patient thinks. It also gives patients a chance to express, and you to resolve, any misunderstandings. Patients may occasionally make an idiosyncratic interpretation of something you said or did. Asking them whether there was anything that bothered them gives them the opportunity to state and then to test their conclusions. In addition to verbal feedback, you may decide to have patients complete a written Therapy Report (see Figure 5.2).
TherapisT: Now at the end of each session, I’m going to ask how you thought the session went. You actually get two chances—telling me directly or writing it on a Therapy Report, which you can fill out in the waiting room after our session. I’ll read it over, and if there are any problems, we can put them on the agenda at our next session.
Okay?
paTienT: Okay.
TherapisT: Now, what did you think of today’s session? Was there any- thing about this session that bothered you or anything you thought I got wrong?
paTienT: No, it was good.
TherapisT: Anything you’d like us to do differently next session?
paTienT: No, I don’t think so.
TherapisT: Okay then. It was a pleasure working with you today. Would you please fill out the Therapy Report in the waiting room now and the other forms I gave you just before our session next week? And you’ll try to do the homework you wrote down on your homework sheet. Okay?
paTienT: (Nods.) Okay. Thanks.
TherapisT: See you next week.
77
Reprinted by permission in Cognitive Behavior Therapy: Basics and Beyond, Second Edition, by Judith S. Beck (Guilford Press, 2011). Permission to photocopy this material is granted to purchasers of this book for personal use only (see copyright page for details). Purchasers may download a larger version of this material from www.guilford.com/p/beck4.
1. What did we cover today that’s important to you to remember?
2. How much did you feel you could trust your therapist today?
3. Was there anything that bothered you about therapy today? If so, what was it?
4. How much homework had you done for therapy today? How likely are you to do the new homework?
5. What do you want to make sure to cover at the next session?
FIGURE 5.2. Therapy Report. From J. S. Beck (2011). Copyight 2011 by Judith S. Beck.
Reprinted by permission.
Q: What if . . . patients have a negative reaction to the session?
A: You will try to specify the problem and establish its meaning to