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.
Explain the structure of a therapy session with a new client. Here is an example of how you can explain structuring a session to a new client. I explain both what I am going to do and why.
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.
Explain the structure of a therapy session with a current client. If you have not been using a struc- tured format, you may feel awkward about introducing a structure with a current client. Here is an example of how you could begin.
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 ses- sions, 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.”
Your Turn!
Practice in Your Imagination:
Explain How a Session Is Structured
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.
Practice with a new client. Imagine yourself in your office with a new client. Take a moment to look around; notice the sounds and smells in the room. Now imagine you want to explain how you would like to structure the sessions. Read over how I explain structuring a session with a new client while imagining yourself saying it. You can also use your own phrases. Really hear and feel yourself explaining how you want to structure the therapy sessions. Now imagine explaining how you want to structure a session two more times with the same client. Each time imagine that your client responds positively.
Practice with a current client. Choose a current client who you think would benefit from, and would like, a structured approach. Try to get a picture of him or her in your mind. Now, imagine yourself in your office. Read over how I explain structuring a session with a current client while imagining yourself saying it. You can also use your own phrases. Now imagine explaining setting a structure two more times with the same client. Each time imagine that your client responds positively.
Agenda Item #2: Start with a Check-In
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.
• Check whether there are any new developments in your client’s life and generally how your client has been since the last session.
• Rate your client’s overall mood since the previous session.
• Bridge to the last session and ask about any issues you are concerned about.
• Review the homework from the last session.
• Identify possible agenda items.
Let’s look at the different components.
Check how your client has been since the last session. You want to know if there have been any changes since the last session and generally how your client has been feeling. If there has been a change in my client’s mood, either for better or worse, I follow up with asking whether anything has changed or how my client understands the change in her mood.
Ask your client to rate her mood. I usually ask my clients to rate their overall mood since the last session. Most non-CBT therapists are not used to rating moods—try it and see whether you and your clients find it helpful. Use a scale of 1 to 10, with 10 being the worst your client has ever felt, and 1 being very happy. Rating helps your client engage in a process of self-reflection. It also gives you a quick sense of how your client is doing and if she is better, the same, or worse since the last session.
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.
Bridge to the last session. This is an opportunity to follow up on any issues from the previous session, including asking about specific areas in your client’s life that you are worried about. For example, if I have a client who has been suicidal, during the check-in I ask about current suicidal thoughts and behavior. If a client is working on a specific issue, such as reducing weekend binge drinking or stopping cutting herself, even if the client doesn’t mention drinking or cutting, I will ask as part of the check-in.
This provides a sense of continuity to the work of therapy.
Review the homework. The check-in is a good time to review any homework, though some therapists review homework as part of setting the agenda. A large meta-analytic study (Mausbach, Moore, Roesch, Cardenas, & Patterson, 2010) found that homework completion was significantly related to a positive outcome in therapy. This means we need to do everything we can to encourage our clients to complete their homework. Asking about and reviewing homework tells your client that homework is important and encourages completion.
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.
Identify possible agenda items. Issues raised in the check-in are often good issues to put on the agenda for the therapy session. For example, if a client tells you that she is thinking of breaking up with her
boyfriend, or that she impulsively spent too much money on clothes again, you can say, “I want to check if this is something that you would like to talk about today” or, “Is this something that we should put on the agenda?” It is important to check, as sometimes when asked, clients realize that this is not really what they want to talk about.