COGNITIVE BEHAVIOR THERAPY
SESSION 2 AND BEYOND
A: For some patients who persist in this belief, it might be helpful to put “Things that can help me feel better and things that can help
me feel worse” on the agenda to discuss later in session. A chart such as the one in Figure 7.2 can help reinforce the notion that patients can take at least minimal control of their mood. Through guided discovery, you can help them see that avoidance, isolation,
Things that make me feel better Things that make me feel worse Riding my bike
Getting through my e-mails Going on facebook meeting up with friends Working on the car
Staying in bed Taking long naps Watching too much TV Sitting around
FIGURE 7.2. A better/worse list.
Structure and Format 105 and inactivity generally increase their dysphoria (or at least does not improve it), while engagement in certain activities (usually that involve interpersonal interaction or that have the potential for pleasure or mastery) can lead to an improvement in their mood, even if initially it is small.
The brief mood check creates several opportunities:
You demonstrate your concern for how patients have been
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feeling in the past week.
You and they can monitor how they have been progressing over
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the course of treatment.
You can identify (and then reinforce or modify) their explanation
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for progress or lack thereof.
You can also reinforce the cognitive model; namely, how patients
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have been viewing situations and how they have been behaving have influenced their mood.
When reviewing objective measures, make sure to review individual items to look for important positive or negative changes (e.g., changes in suicidal ideation or hopelessness). According to patients’ diagnoses and symptomatology, you might also ask for additional information not specifically covered in the tests (e.g., number and severity of panic attacks, binges, substance use, angry outbursts, self-harm, destructive behavior).
If patients are taking medication for their psychological difficul- ties, you will briefly check on adherence, problems, side effects, or questions. It is important to phrase the adherence question in terms of frequency—not “Did you take your medicine this week,” but rather,
“How many times this week were you able to take your medicine the way [the provider] prescribed?” (See, e.g., J. S. Beck, 2001, for suggestions on how to increase medication adherence.)
If you are not the prescribing healthcare provider, you will obtain patients’ permission and then periodically contact the provider to exchange information. You will not recommend changes in medica- tion, but you might help patients respond to cognitions that interfere with their taking medication (or, if applicable, reducing medication). If they have concerns about issues such as side effects, dosage, addiction to medications, or alternative medications or supplements, you will help patients write down specific questions to ask their provider. If patients are not taking medication but you believe a pharmacological intervention is indicated, you might suggest a medical or psychiatric consultation.
Setting an Initial Agenda
The purpose of this brief segment is to set an initial agenda. You social- ize patients into bringing up the names of problems they want help in solving. Rather than asking, “What do you want to talk about today?” or
“What do you want to put on the agenda?”(which can lead to less pro- ductive discussions), you phrase the question in a problem-solving way (until patients are socialized to setting the agenda in this way):
TherapisT: Okay, Sally, what problem or problems do you want my help in solving today? Can you just tell me the names of the problems?
paTienT: Well, I’ve got this economics exam coming up and I just don’t understand the material. I’ve been so worried. I just can’t concen- trate. I don’t know what to do. I keep reading . . .
TherapisT: (gently interrupting) [socializing the patient into briefly specifying a problem to be discussed later in the session] Should we put the exam on the agenda?
paTienT: Yes, definitely.
Rather than having Sally provide a full description of the problem at this point, I gently interrupt her, name the problem, and ask to put it on the agenda to discuss in a few minutes. Had I allowed her to launch into a lengthier description of the problem, I would have deprived her of the opportunity to reflect on and prioritize what she most wanted to talk about during the session, which may or may not have been the first problem she brought up. Next I probe for additional important agenda topics:
TherapisT: Are there any other problems you want help with?
paTienT: Well, things aren’t going too well with my roommate. We keep such different hours. She . . .
TherapisT: (gently interrupting) Should we call that, “problem with your roommate”?
paTienT: Yes.
TherapisT: Anything else?
paTienT: I’m not sure.
TherapisT: [probing for other problems that might be even more important to address during the session than these first two] When did you feel the worst this week?
paTienT: (Thinks.) I guess when I was trying to study for the exam. And in class.
TherapisT: Any other times that were particularly bad?
paTienT: No, those were the worst.
Structure and Format 107 TherapisT: Should we put “studying and class” on the agenda?
paTienT: Yes, that would be good.
I then ascertain whether the patient anticipates the occurrence of other important difficulties before I see her again:
TherapisT: And are there any other problems you think are likely to come up this week?
paTienT: No, I don’t think so.
Q: What if . . . patients have difficulty coming up with agenda items?
A: Often patients need a little encouragement initially to suggest