COGNITIVE BEHAVIOR THERAPY
SESSION 2 AND BEYOND
A: When patients drift into a new topic, you gently interrupt them, calling attention to the change and allowing the patient to make
Structure and Format 111 It is important to note that you need not always adhere to the agenda. Indeed, under some circumstances, you should not follow the agenda. When deviating from the agenda, however, you should explic- itly note the change and elicit the patient’s agreement.
TherapisT: Sally, I can see that you’re still worried about your exam, but we’re running out of time. Would you like to spend the rest of the session on it and postpone our other agenda items to next week? Or we could try to spend just 5 more minutes on it, so we’ll still have time to talk about feeling bad when you’re studying or in class.
paTienT: I guess we should try to get to those things, too.
TherapisT: Okay, let’s both keep an eye on the clock.
You might suggest a change in how you and a patient spend time during a session for a number of reasons. For example, as in the previ- ous transcript, the patient is quite upset about a particular issue and needs more time to discuss it. Or a new topic arises that seems espe- cially important. Or the patient’s mood changes (for the worse) during the session.
Q: What if . . . patients start talking about a whole new topic that is not on the agenda?
A: When patients drift into a new topic, you gently interrupt them,
You steer patients away from peripheral issues that were not on the original agenda, and which hold little promise for helping them prog- ress during the session. A notable exception occurs when you deliber- ately (though usually briefly) engage patients in more casual conversa- tion to achieve a specific goal. For example, you might ask about their family, movies, or social events they have recently attended to brighten their mood, facilitate the alliance, or assess their cognitive functioning or social skills.
THE mIDDlE PART Of THE SESSION
Next you will list the names of the problems on the prioritized agenda and ask patients which problem they want to work on first. Doing so affords them the opportunity to be active and take responsibility. At times, though, you may take the lead in suggesting an agenda item with which to start, especially when you judge that a particular problem is the most important. (“Is it okay with you if we start with the problem of finding a part-time job?”)
You will collect data about the problem, conceptualize the patients’
difficulties according to the cognitive model, and collaboratively decide on which part of the cognitive model you will begin working (solving the problem situation, evaluating automatic thoughts, reducing patients’
immediate distress (if the patients’ affect is so high they cannot focus on problem solving, evaluating thoughts, or behavioral change), sug- gesting behavioral changes (and teaching behavioral skills if needed), or decreasing patients’ physiological arousal (if it is interfering with an important discussion). In the context of discussing problems on the agenda, you will be teaching patients skills and setting new homework.
You will also make periodic summaries, if needed, to help you and the patient recall what you have been doing in this part of the session.
In discussing the first problem (and subsequent problems), you will interweave your therapy goals as appropriate. In this second session, I seek not only to help Sally do some problem solving, but also to:
Reinforce the cognitive model.
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Continue teaching Sally to identify her automatic thoughts.
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Provide some symptom relief through helping Sally
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respond to her anxious thoughts.
As always, maintain and build rapport through accurate
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understanding.
Structure and Format 113
Agenda Item No. 1
TherapisT: Okay, let’s take a look at the agenda. Where do you think we should start? We could talk about your exam, your mood when you’re studying or when you’re in the library, or the course of improvement.
paTienT: My economics exam, I guess, I’m really worried about it.
TherapisT: [collecting data] Okay, can you give me an overview of what happened this week? How much did you study? What hap- pened with your concentration?
paTienT: Well, I meant to study all the time. But every time I sat down, I just got so nervous. Sometimes I didn’t realize that my mind had wandered, and I had to keep rereading the same page.
TherapisT: [continuing to collect data so I can help problem-solve and identify possible distortions in Sally’s thinking] When is the exam, and how many chapters does it cover?
paTienT: It’s in 2 weeks, and I think it covers the first five chapters.
TherapisT: And how many chapters have you read at least once?
paTienT: About three.
TherapisT: And there are still some things in these first three chapters that you don’t understand?
paTienT: A lot of things.
TherapisT: Okay. So, in a nutshell, you have an exam in 2 weeks, and you’re worried that you won’t understand the material well enough?
paTienT: Right.
In this first part, I seek an overview of the problem. I subtly model how to express this problem succinctly. Next, I help Sally identify her auto- matic thoughts by having her recall a specific situation.
TherapisT: Can you remember a time this week when you thought about studying or tried to study, and the anxiety got really bad?
paTienT: Yes, sure . . . last night.
TherapisT: What time was it? Where were you?
paTienT: It was about 7:30. I was walking to the library.
TherapisT: Can you picture it in your head now? It’s 7:30, you’re walk- ing to the library. . . . What goes through your mind?
paTienT: What if I flunk the exam? What if I flunk the course? How will I ever make it through the semester?
TherapisT: Okay, so you were able to identify your automatic thoughts.
And how did these thoughts make you feel? Anxious?
paTienT: Very.
TherapisT: Let me tell you a little more about these automatic thoughts.
We call them automatic because they seem just to pop into your mind. Most of the time, you’re probably not even aware of them;
you’re probably much more aware of how you’re feeling emotion- ally. Even if you are aware of them, you probably don’t think to evaluate how accurate your thoughts are. You just accept them as true.
paTienT: Hmmm.
TherapisT: What you’ll learn to do here in therapy is first to identify your thoughts, and then judge for yourself whether they’re com- pletely true, partially true, or not true at all. (pause) Can we look at the first thought together? [starting the process of evaluating the automatic thought] What evidence do you have that you’ll flunk the exam?
paTienT: Well, I don’t understand everything.
TherapisT: Anything else?
paTienT: No . . . just that I’m running out of time.
TherapisT: Okay. Any evidence that you might not flunk?
paTienT: Well, I did do okay on the first quiz.
TherapisT: Anything else?
paTienT: I guess I understand the first two chapters better than the third one. The third one is the one I’m really having trouble with.
TherapisT: [starting problem solving; having Sally take the lead] What could you do to learn the third chapter better?
paTienT: I could read it again. I could look through my lecture notes.
TherapisT: Anything else?
paTienT: (Hesitates.) I can’t think of anything.
TherapisT: Anyone else you could ask for help?
paTienT: Well, I suppose I could ask Sean; he’s the teaching assistant.
Or maybe Ross, the guy down the hall who took this course last year.
TherapisT: That sounds good. Did you think of asking either of them for help this week? Did any automatic thoughts get in the way?
paTienT: No, I guess I just didn’t even think of it.
Structure and Format 115 TherapisT: Whom do you think would be better to ask?
paTienT: Sean, I guess.
TherapisT: How likely are you to ask him?
paTienT: I will. He has office hours tomorrow morning.
TherapisT: Okay, assuming you get help this week, what do you think of your prediction that you might flunk?
paTienT: Well, I guess I do know some of the stuff. Maybe I could get help with the rest.
TherapisT: And how do you feel now?
paTienT: A little less worried, I guess.
TherapisT: Okay, to summarize, you had a lot of automatic thoughts this week that made you feel anxious. But when you stop to evaluate these thoughts, it seems likely that there are some things you can do to pass. When you really look at the evidence and answer the thoughts, you feel better . . . Is that right?
paTienT: Yeah, that’s true.
TherapisT: For homework this week, I’d like you to look for these auto- matic thoughts again when you notice your mood changing. These thoughts may have a grain of truth, but often I think you’ll find that they’re not necessarily completely true. Next week we’ll look for evidence together to figure out whether the thoughts you wrote down for homework are completely accurate. Okay?
paTienT: Okay.
TherapisT: Now, identifying and evaluating thoughts is a skill for you to learn, like learning to drive or type. You may not be very good at it at first, but with practice you’ll get better and better. And I’ll teach you more about this in future sessions. See what you can do this week just to identify some thoughts, but don’t expect yourself to be good at it yet. Okay?
paTienT: Yeah.
TherapisT: One more word about this. When you write down some thoughts this week, remind yourself again that the thoughts may or may not be true. Otherwise, writing them down before you’ve learned to evaluate them could make you feel a little worse.
paTienT: Okay.
TherapisT: Let’s write this assignment down. And while we’re at it, let’s see if there’s anything else you want to do to get ready for the test.
[See Figure 7.3.]
In this section, I accomplish many things at once. I address a prob- lem from the agenda that is of concern to Sally; I teach her more about automatic thoughts; I help her identify, evaluate, and respond to a specific distressing thought; I facilitate symptom relief by decreasing her anxiety; and I set up a homework assignment and advise Sally to have realistic expectations about learning the new skill. Chapters 9–12 describe in greater detail the process of teaching patients to identify and evaluate their automatic thoughts.
Q: What if . . . I don’t know how to help patients solve a particular problem?