COGNITIVE BEHAVIOR THERAPY
A: In this case, you will need to spend more time finding out precisely what occurred, especially whether the therapist provided treat-
ment individualized for the patient and his specific disorder(s), based on the latest research and practice guidelines. In any case, you can encourage the patient to give your treatment a try for a few sessions and indicate that you will then jointly review whether the treatment seems to be working.
ExPECTATIONS fOR TREATmENT
At this session, you will give patients a general sense of how long they should expect treatment to take. Usually it is best to suggest a range, 2–4 months for many patients with straightforward major depression, although some might be able to terminate sooner (or might have to, due to financial constraints or insurance limitations). Other patients, par- ticularly those with chronic psychiatric disorders, or those who want to work on problems related to a personality disorder, may remain in treat- ment for a year or more. And patients with severe mental illness may need more intensive treatment when they are more highly symptomatic, and periodic booster sessions for a very long time (along with medication).
Most patients progress satisfactorily with weekly sessions unless they are severely depressed or anxious, suicidal, or clearly in need of more support. Toward the end of treatment, you may gradually space sessions further apart to give patients more opportunities to solve prob- lems, make decisions, and use their therapy tools independently.
In the following transcript, I give Sally an idea of how I expect therapy will proceed.
TherapisT: If it’s okay with you, Sally, we’ll plan to meet once a week until you’re feeling significantly better, then we’ll move to once every 2 weeks, then maybe once every 3 or 4 weeks. We’ll decide how to space out therapy together. Even when we decide to end, I’ll recommend that you come back for a “booster” session once every few months for a while. How does that sound?
paTienT: Fine.
TherapisT: It’s hard to predict now how long you should be in therapy.
My best guess is somewhere around 8 to 14 sessions. If we find that you have some long-standing problems that you want to work on, it could take longer. Again, we’ll decide together what seems to be best. Okay?
The Evaluation Session 57
Between the Evaluation and First Therapy Session
Before the first therapy session, you will write up your evaluation report and initial treatment plan. If you have obtained consent, you will con- tact the patient’s previous mental health and health professionals to request reports, ask questions, and obtain additional information. You will also contact relevant current professionals to discuss your findings and coordinate care. Conversations by phone can reveal important information that had not been documented in writing. You will also start to devise a tentative cognitive conceptualization.
DEVISING AN INITIAl COGNITIVE CONCEPTUAlIzATION AND TREATmENT PlAN
You will synthesize the information you gleaned from the evaluation to develop an initial cognitive conceptualization, informed by the cogni- tive formulation (the basic beliefs and behavioral patterns) associated with the patient’s diagnosis. You will hypothesize about the develop- ment of the patient’s disorder.
“Were there important early life events that led to the development of negative core beliefs?”
“What are the patient’s core beliefs?”
“What precipitated the disorder?”
“Did the patient put an adverse construction on certain precipitating events?”
“How do the patient’s thinking and behavior contribute to the maintenance of the disorder?”
You will then use the conceptualization to develop a broad treatment plan.
Pulling together what I had learned from the evaluation, I hypoth- esized that Sally was vulnerable to seeing herself as incompetent (a belief that developed as a result of interactions with her parents, sibling, and some teachers). When she entered college, Sally began to perceive herself as unable to meet the new demands of school and independent living. She began to develop a generalized sense of incompetence; that is, a core belief of incompetence became activated. She began to have many automatic thoughts across situations about the likelihood that she would fail. These thoughts led her to feel sad, anxious, and hope- less. She was affected behaviorally, as well. She began to give up, spend-
ing too much time alone in her room. She failed to persist in doing assignments she viewed as difficult, and she began to fall behind in her schoolwork. She saw her difficulties as an innate flaw, and not as the result of depression. A paucity of pleasure and mastery activities increased her dysphoria (see Appendix A).
Understanding the cognitive model of depression and being famil- iar with the major treatment strategies for depression, I developed a more specific treatment plan than the simplified one I had presented to Sally. I hypothesized that I would initially need to focus on the fol- lowing: helping her solve academic and daily living problems; encour- aging her to become much more active; and teaching her to identify, evaluate, and modify her inaccurate or unhelpful negative thinking, especially thoughts associated with failure and incompetence (since she had expressed those ideas). I hypothesized that we would work more directly on her core belief of incompetence toward the middle of treatment, but I did not yet know whether it would be important to include a focus on the historic antecedents to her belief. I also did not know at this point whether Sally had dysfunctional beliefs associated with unlovability or worthlessness (see Chapter 14) that we would have to modify; she had not provided data to support the existence of these beliefs at the evaluation. I planned to emphasize relapse prevention in the final part of treatment. I continued to refine this basic treatment plan throughout therapy as I got to know Sally and the nature of her difficulties better.
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Chapter 5
STRUCTURE Of THE fIRST THERAPY SESSION
I
n this chapter, you will learn how to structure the initial session, including how to:Discuss the patient’s diagnosis.
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Do a mood check.
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Set goals.
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Start working on a problem.
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Set homework.
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Elicit feedback.
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Most patients feel comfortable when you tell them how and why you would like to structure sessions. Doing so demystifi es the process of therapy and keeps treatment on track. Chapter 6 focuses on an essen- tial component for depressed patients: initiating behavioral activation.
Chapter 7 describes the common structure for subsequent sessions, and Chapter 8 discusses problems in structuring sessions.
GOAlS AND STRUCTURE Of THE INITIAl SESSION Before the fi rst session, you will review the patient’s intake evaluation and you will keep your initial conceptualization and treatment plan
in mind as you conduct the session, being prepared to change course if need be. Most standard cognitive behavior therapy sessions last for about 45–50 minutes, but the first one often takes an hour. Your goals for the first session are to:
Establish rapport and trust with patients, normalize their
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difficulties, and instill hope.
Socialize patients into treatment by educating them about their
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disorder(s), the cognitive model, and the process of therapy.
Collect additional data to help you conceptualize the patient.
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Develop a goal list.
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Start solving a problem important to the patient (and/or get the
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patient behaviorally activated).
To accomplish these goals, you will use the following format:
Initial Part of Session 1
1. Set the agenda (and provide a rationale for doing so).
2. Do a mood check.
3. Obtain an update (since the evaluation).
4. Discuss the patient’s diagnosis and do psychoeducation.
Middle Part of Session 1
5. Identify problems and set goals.
6. Educate the patient about the cognitive model.
7. Discuss a problem.
End of Session 1
8. Provide or elicit a summary.
9. Review homework assignment.
10. Elicit feedback.
SETTING THE AGENDA
As this is the first session, you will begin by greeting the patient and set- ting the agenda. Doing so frequently reduces patients’ anxieties, as they quickly find out what to expect. You will provide a rationale and make sure the patient agrees with the topics you propose. (In future sessions,
Structure of the First Therapy Session 61 you will set the agenda sometime in the initial part of the session, but not necessarily at the very beginning.)
TherapisT: Sally, I’m glad you came in today. Is it all right if we start off by deciding what we’re going to talk about today? It’s what we call
“setting the agenda.” We’ll do this at the beginning of every ses- sion [providing a rationale] so we make sure we have time to cover what’s most important to you. I have a list of things I’d like to go over today, and then [being collaborative] I’ll ask you what you’d like to add. Is that okay?
paTienT: Yes.
TherapisT: Our first session will be a little different from future ses- sions, because we have a lot of ground to cover and we need to get to know each other better. Here’s what I’d like to go over. First, in a couple of minutes [alerting Sally that I don’t want to dive into a topic before setting a complete agenda], I’d like to check on how you’ve been feeling, find out what’s happened since the evaluation, and talk a little about your diagnosis. (pause) Then I’d like to set some more specific goals. Does that sound okay?
paTienT: Yes.
TherapisT: Along the way, we might figure out some things for you to do before we meet again, [behavioral activation] especially making some changes in your schedule. And at the end, I’ll ask you what you thought about the session. [eliciting feedback] How does that sound?
paTienT: Fine.
TherapisT: Is there anything you want to add to the agenda today?
paTienT: Well, I know I should be doing more. But I’m so tired. It’s just so hard to concentrate on my work and go out with friends. I end up spending a lot of time sleeping or watching TV and . . .
TherapisT: (gently interrupting) Is it okay if I interrupt you for a moment?
How about if I put “doing more things” on our agenda, and we’ll try to get to it today?
paTienT: Okay.
TherapisT: (jotting down this agenda item) You’ll notice that I tend to write down a lot of things during our session. [providing a ratio- nale] I want to make sure to remember what’s important . . . Okay, anything else even more important for the agenda today?
paTienT: No, I don’t think so.
TherapisT: If you think of other important things as we go along, just let me know.
Ideally, setting the agenda is quick and to the point. Explaining the rationale for why you want to set an agenda makes the process of ther- apy more understandable to patients and elicits their active participa- tion in a structured, productive way.
Q: What if . . . patients express a strong preference to spend therapy time in another way?
A: Patients occasionally, though infrequently, balk at the agenda you present for this first session. This might happen for several rea- sons. You may have presented the agenda in too controlling a fashion, without being collaborative. There may be pressing issues on their mind for which they desperately want immediate help in the session. They might prefer to spend the session talking freely about whatever comes in their mind, without structure or inter- ruption.
What do you do? Above all, you need to engage patients so they will return to treatment for the next session. If you judge that trying to persuade patients to adhere to your agenda will endan- ger their engagement, especially in this first session, you might offer to split the therapy time. If they demur, you can spend the session doing what they want. At the next session, you will find out whether doing so helped alleviate their suffering significantly during the week. If not, they may be more motivated to spend at least part of the session discussing what you think is important to help them feel better.
DOING A mOOD CHECk
Having set the agenda, you will next do a brief mood check. In addition to asking Sally for a brief narrative report of her mood since I saw her last, I quickly review the symptom checklists she filled out just prior to the session (see Appendix B for information about the Beck Depres- sion Inventory, Anxiety Inventory, and Hopelessness Scale). Because I initially just want a brief overview of her mood, I cue her to provide me with an answer in just a few words.
TherapisT: Okay, next. Can we start with how you’ve been doing this week? I’d like to see the forms you filled out. While I look them over, [providing a guideline] can you tell me in a sentence or two how you felt for most of the week?
paTienT: I’ve been really depressed the whole time.
Structure of the First Therapy Session 63 TherapisT: (looking over the forms) It looks as if you’ve been feeling
pretty anxious, too, is that right?
paTienT: Yes.
TherapisT: [being collaborative] If it’s okay with you, I’d like you to come to every session a few minutes early so you can fill out these three forms. [providing a rationale] They help give me a quick idea of how you’ve been feeling in the past week, although I’ll always want you to describe how you’ve been doing in your own words, too.
paTienT: Okay.
In this first session, as in every session, I note the summed scores of the objective tests, comparing them to the scores from the evaluation. I also quickly scan individual items to determine whether the tests point out anything of particular importance. I especially note items related to hopelessness and suicidality on the Beck Depression Inventory–II. If these items are elevated, I will do a risk assessment (Wenzel et al., 2008) to determine whether we need to spend the next part of the session developing a plan to keep the patient safe.
Q: What if . . . patients cannot or will not fill out objective tests?
A: If you do not have access to symptom checklists, if they are inap- propriate for patients (e.g., patients aren’t sufficiently literate), or if they express reluctance about completing them, you can teach them, at this initial session or at the next session, to rate their mood on a 0–10 scale: “Can you think back over the past week?
If 0 means not depressed at all, and 10 means the most depressed you’ve ever been, what has your depression been like for most of the week?” Or you can ask patients, “Can you tell me about your depression this week? Would you say it was mild, moderate, or severe? How did your mood compare to other weeks?” Other problems related to doing a mood check are discussed in Chap- ter 8.
OBTAINING AN UPDATE
In the next part of the session, you will question patients to discover whether there are any important problems or issues that they have not yet mentioned that might take priority in the session. Then you will probe for positive experiences the patient had during the week.
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