Let’s look at an example of how a check-in might work. This is Suzanne’s fourth session and her therapist has already explained using a structured session. Before reading the dialogue below, ask your- self: how would you start the session?
Therapist: Hello, good to see you. I would like to check in, see how your week has been, make a list of what you would like to focus on today, and hear how the homework went.
Suzanne: (looking downcast) Well, my week has been pretty much the same and pretty awful. I did the homework and have it here.
Suzanne’s therapist wants to follow up on the homework but also wants her to rate her mood and continue with the check-in.
Therapist: It’s great that you did the homework; I want to follow up on it, but first I want to get an overall sense of your week and check what we need to focus on today. Is that okay with you? (Suzanne nods.) I was wondering…if you were to rate your mood over the past week, where would you put it?
Note how the therapist redirects Suzanne to the tasks of the check-in.
Suzanne: Probably overall a 7; I just felt really down a lot of the time.
Therapist: So the same as last week. Were there any times that were particularly hard, or any times when your mood was better?
Suzanne: I’m not sure, I was pretty down most of the week. Home is still the same. I can’t stand the new school. I think the teachers are really awful. No matter how hard I try, I just don’t fit in. (Sounding more upset and agitated.) One of the teachers asked me what I do at lunch, since she never sees me in the lunchroom. I didn’t know what to say.
This could be a good issue to focus on in therapy as it relates to Suzanne’s goal of “trying to fit into the new school.” However, it is also not a crisis issue and other issues might be more important. Notice her therapist did not respond, “How did you feel when she asked you what you do at lunch?” or “Tell me more about that,” as these responses would encourage Suzanne to keep talking about that incident.
Therapist: Sounds like you were pretty upset by the teacher’s comment. Before we talk more about it, I want to check if that was the main thing you wanted to talk about or whether there were other issues.
Suzanne: That just happened this morning. I don’t really want to spend time on it; it’s not that important.
At this point in the check-in, Suzanne has indicated that there have not been any changes in her life and
she has rated her overall mood. There is nothing the therapist wants to raise as a bridge from the last
session. The next step is to discuss the homework and set an agenda.
Your Turn!
Help Raoul Stay Focused During the Check-In
Let’s see how Raoul’s therapist uses the check-in.
Therapist: Hello, good to see you. I would like to check in, see how your week has been, see what you would like to focus on today, and go over your homework.
Raoul: (looking agitated) I’ve been really anxious all week. I have a major deadline on a project that’s due, and I am way behind. My boss must think I am a total loser.
My anxiety is through the roof. I don’t know what’s the matter with me, I should just do the project.
Look at the three possible responses below. Choose the response that will help Raoul stay focused on checking in.
1. I can see why you would be anxious. You have done really good work in the past. What makes you think that your boss thinks you are a loser?
2. Let’s see if we can help you with your deadline. What do you need to do to meet the deadline?
3. Sounds like it would be important for us to look at what is going on with the project. Before we do that, I want to check whether anything else happened this week that is important to you.
Response #3 keeps Raoul focused on the check-in and structure of therapy. His therapist is also dem- onstrating empathy about the urgency of the project. In response #1, the therapist tries to be supportive but assumes that this issue with the boss is the main agenda item and has not checked in or set an agenda. In response #2, the therapist starts to problem solve without being sure this is the topic Raoul wants to focus on.
Therapist Sounds like it would be important for us to look at what is going on with the project. Before we do that, I want to check whether anything else happened this week.
Raoul: I’ve been so anxious, I haven’t been sleeping, but otherwise nothing is really new.
In this situation you have an agenda item that came from the check-in. Before you start discussing the agenda item, you need to ask Raoul to rate his overall mood during the week, and check if there are any other issues he would like to talk about in therapy. All you need to say is, “Before we talk about your difficulties with the project, I want to do a quick check on how your overall mood has been this past week. How would you rate your mood, from 1 to 10?”
Exercise 4.1: Eulela Has a Very Bad Week
Practice keeping the check-in focused when the client has multiple problems.
Agenda Item #3 : Collaboratively Set an Agenda
Setting an agenda involves collaborating with your client to make a list of what she wants to focus on in the session. Some therapists think that setting an agenda sounds like a business meeting, but it is actually very client focused. When you set an agenda you are saying, “I care that our therapy focuses on what is important to you, so at the beginning of our session I want to spend a few minutes checking on what you want to talk about.” The process involves the client expressing her needs, and you, the therapist, hearing and responding to her needs. This can be very empowering for your client.
Setting an agenda also sets the expectation that therapy is not just about coming and talking; you expect your client to work on specific problems and to give some thought to what she wants to talk about. You, the therapist, can also add issues to the agenda. For example, if you talked with a teenager’s probation officer or parent, this would be a good time to let the teen know and add it to the agenda. It is helpful to write out the agenda and place it where you and your client can both see it. Many thera- pists have a white board or flip chart in their office, but you can also use a piece of paper.
Clear Agenda Focused Therapy Effective Therapy and Satisfied Clients
One of the many things I like about setting agendas is that it helps with what I call “doorknob therapy.” Doorknob therapy is when you have finished the session and your client has a hand on the doorknob, ready to leave, and says, “Oh I forgot, I wanted to talk to you about this really important issue.” You can then say, “That sounds like an important issue. Can we put it on the agenda for next time, and start with it?” If your client regularly raises important issues at the end of therapy, you can start therapy by saying, “The last couple of sessions it wasn’t until the end that you remembered an important issue you wanted to talk about. I thought it might be helpful to take a moment and think about what you want to talk about today.” As your client learns to set an agenda for her therapy session, she is taking responsibility not only for her therapy, but also for making changes in her life.
Once you have a list of agenda items, the next step is to ask the client which issue she would like to start with. If a client has a large number of issues on the agenda, I simply say, “There are too many issues for us to talk about all of them today. Let’s choose two or three and see if we can start to work on them.” It can also be helpful to decide roughly on the amount of time you will spend on each issue.
At about the midpoint of the session I usually let my client know the time and ask whether she wants to stay on the issue we are discussing or move to the next issue on the agenda.
Below are some helpful questions for setting an agenda. You can download a Questions to Help Set an Agenda handout at http://www.newharbinger.com/38501.
• What would you like to focus on today?
• What shall we put on the agenda for today?
• Should we make a list of what you would like to talk about today, and then choose where you would like to start?