COGNITIVE BEHAVIOR THERAPY
A: There are several reasons for deviating from the usual structure in the first session
TherapisT: Next, what happened between the evaluation and now that’s important for me to know?
paTienT: (Thinks.) Well, my parents have been putting pressure on me to figure out what I’m going to do this summer.
TherapisT: [collecting data about the problem to establish whether it’s of immediate importance and of high priority] Has this been really upsetting to you?
paTienT: (Sighs.) Not that much. It’s just one more thing.
TherapisT: Is this something you want my help with?
paTienT: Yes, I guess so.
TherapisT: We don’t have a lot of time today. Do you think we could postpone talking about it until another time?
paTienT: That’s okay.
TherapisT: I’ll put it at the bottom of my notes, and ask you next week how high a priority it is for you.
paTienT: Okay.
TherapisT: Was there anything else that was really important this week?
paTienT: No, I guess not. It was pretty much the same as last week.
By asking these questions, I find out that there is not an important problem that needs to take priority over what is already on the agenda, so I can move ahead.
How do you decide which problems are pressing and which are not? You will establish how distressed the patient is by the problem and whether the patient really needs to solve it immediately (e.g., not solv- ing it could put the patient or others in harm’s way, or endanger the patient’s livelihood or living situation). Discussion of most problems, especially chronic ones (such as difficulty functioning at home or argu- ments with family members), can usually be postponed to a future ses- sion so you can cover what you need to in this initial session.
Q: What if . . . there had been a pressing agenda item?
A: There are several reasons for deviating from the usual structure
Structure of the First Therapy Session 65 ing the problem that the therapeutic relationship could be impaired, and/or that the patient is likely not to come back for another session.
When you ask patients for an update early in treatment, they invari- ably report only negative experiences. You then ask, “What positive things happened this week?” or “When were some times that you felt even a little bit better this week?” These questions help patients see real- ity more clearly, as the depression has undoubtedly led them to focus almost exclusively on the negative.
DISCUSSING THE DIAGNOSIS
In the next part of the session, you will briefly review patients’ present- ing problems and ask them to bring you up to date:
TherapisT: Sally, I’d like to discuss what I found out in the evaluation session last week. Is it okay if we talk for a few moments about your diagnosis?
Most patients want to know their general diagnosis, and to establish that you don’t think they are strange or abnormal. Usually it is prefer- able to avoid the label of a personality disorder diagnosis. Instead it is better to say something more general and jargon free, such as, “It looks as if you’ve been pretty depressed for the last year and you’ve had some long-standing problems with relationships and with work.”
It’s also desirable to give patients some initial information about their condition so they can start attributing some of their problems to their disorder instead of to their character (“There’s something wrong with me. I’m just no good.”) The following transcript illustrates how to edu- cate patients who are depressed.
TherapisT: The evaluation shows that you have a moderate depres- sion. I want you to know that it’s a real illness. It’s not the same as people saying, “Oh, I’m so depressed” when they’re feeling down.
You have a real depression.
paTienT: (Sighs.)
TherapisT: I know that because you have the symptoms in this diag- nostic manual (showing Sally the DSM). For each mental health dis- order, this manual lists the symptoms, just as a neurology diagnos- tic manual would list the symptoms of a migraine.
paTienT: Oh, I didn’t know that.
TherapisT: [providing hope] Fortunately, cognitive behavior therapy is very effective in helping people overcome depression.
paTienT: I was afraid you’d think I was crazy.
TherapisT: Not at all. [normalizing] You have a fairly common condi- tion, and it sounds as though you have a lot of the same problems as most of our patients here. But that’s typical of how people with depression think. How do you feel now that you’ve found out I don’t think you’re crazy?
paTienT: (Sighs.) Relieved.
TherapisT: That’s a lot of what we’ll be doing in treatment. Identifying your depressed thinking and helping you see things more realisti- cally.
paTienT: Okay.
TherapisT: [anticipating that Sally might blame herself for thinking in an unrealistic way] Now, it’s not your fault that you have this kind of negative thinking. It’s a primary symptom of depression. For every- one with depression, it’s as if they’re seeing themselves and their worlds and the future [the “cognitive triad” of depression] through eyeglasses covered with black paint. (I pantomime painting an imagi- nary pair of glasses on my face.) These dark glasses make everything look dark and hopeless. Part of what we’ll do in therapy is to scrape off the black paint (pantomiming) so you can see things more real- istically . . . Is that clear? [Using an analogy often helps the patient to see her situation in a different way.]
paTienT: Yeah. I understand.
TherapisT: Okay, let’s go over some of the other symptoms of depres- sion that you have. I see from the evaluation that the depression is interfering with your sleep and your energy. It sounds as if it’s also affecting your motivation to do things. [normalizing] Now, most depressed people start criticizing themselves for not being the same as they had been before. [eliciting specific incidents] Do you remember any recent times you’ve criticized yourself?
paTienT: (Sighs.) Yeah. Lately I’ve been getting out of bed late and not getting my work done, and I think I’m lazy and no good.
TherapisT: Now, if you had pneumonia, and had trouble getting out of bed and getting everything done, would you call yourself lazy and no good?
paTienT: No, I guess not.
TherapisT: Would it help this week if you answered back the thought,
“I’m lazy and no good”?
Structure of the First Therapy Session 67 paTienT: Probably.
TherapisT: What could you remind yourself? [Eliciting a response rather than just providing one fosters active participation and a degree of autonomy.]
paTienT: I guess that I am depressed, and it’s harder for me to do things.
TherapisT: Good. It’s going to be really important for you to remem- ber that this week. Would you like me to write it down? Or would you like to?
paTienT: You can.
TherapisT: (pulling out a piece of carbonless paper [see Figure 5.1]) Okay, I’ll date this paper at the top. Now what should we call this: your therapy homework? Your action plan?
paTienT: Homework, I guess.
TherapisT: Good. (Writes “Homework” at the top.) The first item is to read something about what we just discussed. I’ll write down, “If I start thinking I’m lazy and no good, remind myself that I have a real ill- ness, called depression, that makes it harder for me to do things.”
(pausing and anticipating that this statement could lead to hopelessness) Is it okay if I write down another reminder? “As the treatment starts to work, my depression will lift, and things will get easier.”
Jan. 22 Homework:
Read this list twice a day; set an alarm to remember.
1. If I start thinking I’m lazy and no good, remind myself that I have a real illness, called depression, that makes it harder for me to do things. As the treatment starts to work, my depression will lift, and things will get easier.
2. Read goal list and add others, if I think of any.
3. When I notice my mood getting worse, ask myself, “What’s going through my mind right now?” and jot down the thoughts. Remind myself that just because I think something, doesn’t necessarily mean it’s true.
4. make plans with Allison and Joe. Remember, if they say no, it’s likely that they’d like to hang out with me but they’re too busy.
5. Read Coping with Depression booklet (optional).
FIGURE 5.1. Sally’s first-session homework list.
Q: What if . . . the patient negates the analogy?
A: Some patients say, “Yes, but pneumonia is a biological disease.” A