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 evalu- ation! 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.
Agenda Item #4: Work the Agenda
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 discuss- ing 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.
Exercise 4.2: Dewei Uses Marijuana Again
Practice keeping to a structured session.
Video 4.1: Check In and Set an Agenda
Agenda Item #5: Develop Helpful Homework for the Next Session
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.
• Developed collaboratively with your client
• Specific and concrete
• Related to the session
• Doable
Developed collaboratively. Ideally, the homework comes out of a discussion with your client. I often start with asking, “What do you think would be a good way to practice what we have talked about today during the coming week?” While your client may have some good suggestions, frequently it is the therapist who suggests specific homework. It is important to check your client’s reaction to any home- work that you suggest. I usually say, “One idea I had was for you to… What do you think?” My clients often have good ideas about how to modify my suggestions.
Specific and concrete. You and your client need to be clear on what she is going to do for homework.
To decide if the homework is specific and concrete, ask yourself: Is there a specific behavior my client is going to try? How often will my client do the homework? Where and when will my client do the homework? For example, “Try to notice your negative thoughts” is not very specific or concrete. A more specific assignment would be, “When you get angry at your teacher in science class, write down the thoughts that go through your mind. Do you think you can do this twice this coming week?” Your client then knows what she will do, in what situation, and how often.
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?
Related to the session. Clients are more likely to complete homework that flows from the session. Let’s go back to Suzanne. One of her sessions focused on identifying specific situations she found difficult at school. Listening to a relaxation tape would not be an effective homework task. While she might find the tape helpful, it is not related to what she talked about in session. A better homework assignment would be an activity related to the situations she found difficult at school. Effective homework is also related to a client’s overall goals.
Doable. Be sure to ask your client whether the homework seems doable and if she foresees any obsta- cles. If your client does foresee obstacles, problem solve how to overcome them.
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 guide- lines 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?
Therapist: We have about five minutes left in our session. You said you would like to start doing some of the fun activities you used to enjoy with your children. Does that give you any ideas for homework this coming week?
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
whethershe has any ideas.
Suzanne: No, not really.
Therapist: I am wondering if you could think of one activity that you used to do with your children that you would like to start doing again this week.
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.”
Exercise 4.3: (a) Renee Tries to Catch Up at School, and (b) Wilson Feels Tense
Practice using the homework guidelines.
Agenda Item #6: Review the Session and Ask for Feedback
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.