COGNITIVE BEHAVIOR THERAPY
SESSION 2 AND BEYOND
A: There are several things you can do
In this section, I accomplish many things at once. I address a prob- lem from the agenda that is of concern to Sally; I teach her more about automatic thoughts; I help her identify, evaluate, and respond to a specific distressing thought; I facilitate symptom relief by decreasing her anxiety; and I set up a homework assignment and advise Sally to have realistic expectations about learning the new skill. Chapters 9–12 describe in greater detail the process of teaching patients to identify and evaluate their automatic thoughts.
Q: What if . . . I don’t know how to help patients solve a particular problem?
Structure and Format 117
• If you’re stuck, postpone the discussion: “I’d like to think more about the problem this week. Could we put it on the agenda to talk more about next week?”
Also, see pages 256–258 for a further description of problem solv- ing.
Agenda Item No. 2
In the next section of the therapy session, I provide Sally with some information about the course of improvement. Having just finished a segment of the session, I briefly summarize first:
TherapisT: Okay, we just finished talking about your exam and how your automatic thoughts really made you feel anxious and inter- fered with problem solving. Next, I’d like to talk about the course of getting better, if that’s okay.
paTienT: Sure.
TherapisT: I’m glad you’re feeling a little less depressed today, and I hope you continue to feel better. But probably you won’t just feel a little bit better every single week until you’re back to your old self.
You should expect to have your ups and downs. Now I’m telling you this for a reason. Can you imagine what you might think if you expected to keep feeling better and better and then one day you felt a lot worse?
paTienT: I’d probably think I would never get better.
TherapisT: That’s right. So I want you to remember that we predicted a possible setback, that setbacks are a normal part of getting better.
Do you want to get down something in writing about that?
See Chapter 18 for a more extensive discussion of relapse prevention and a pictorial representation of the normal course of therapy.
Periodic Summaries
Three kinds of summarizing are important throughout sessions. The first summarizes content. Patients often describe a problem with many details. You will summarize what they have said in the form of the cog- nitive model to ensure that you have correctly identified what is most troublesome to patients, and to present it in a way that is more concise and clear. You use patients’ own words as much as possible, both to convey accurate understanding and to keep the key difficulty activated in their mind:
TherapisT: Let me make sure I understand. You were considering get- ting a part-time job again, but then you thought, “I’ll never be able to handle it,” and the thought made you so sad that you turned off your computer and went back to bed and cried for half an hour. Is that right?
Had I paraphrased the patient’s ideas and failed to use her own words (“Sounds like you weren’t sure if you could do well if you got a part- time job”), I might have lessened the intensity of the automatic thought and emotion, and our subsequent evaluation of the thought might then have been less effective. Summaries that substitute the therapist’s words may also lead to patients’ believing that they have not been accurately understood:
paTienT: No, it’s not that I thought I might not do well; I’m afraid I might not be able to handle it at all.
You will often ask patients to make a second kind of summary after you have evaluated an automatic thought or belief:
“Can you summarize what we just talked about?”
Or“What do you think the main message is here?”
Or“What do you think would be important for you to remember?”
If patients do a good job of summarizing, you or they should write down this summary so they can read it for homework. If their summary misses the mark, you might say, “Well, that’s close, but I wonder if it would be more helpful if you remembered it this way . . .” If the patient agrees, the latter summary is recorded in their notes.
The third is a brief summary when a section of a session has been completed, so both therapist and patient have a clear understanding of what they have just accomplished and what they will do next:
TherapisT: Okay, so we’ve finished talking about the course of treat- ment. Next, should we talk about the problem with your cousin?
fINAl SUmmARY AND fEEDBACk
The goal of the final summary is to focus the patient’s attention on the most important points of the session in a positive way. In early sessions, you will generally summarize.
Structure and Format 119 TherapisT: Well, we have just a few minutes left. Let me summarize
what we covered today, and then I’ll ask you for your reaction to the session.
paTienT: Okay.
TherapisT: It sounds like when you had more hopeful thoughts this week, you felt less depressed. But then your anxiety increased because you had all these negative thoughts about your exam.
When we looked at the evidence that you’ll flunk, though, it seemed unconvincing. And you came up with a couple of good strategies to help your studying, some of which you’ll try between now and our next session. We also discussed what you should remind yourself if you have a setback. Finally, we talked about having you continue to go running. And we went over identifying and evaluating your automatic thoughts, which is a skill we’ll keep practicing in therapy.
(pause) Do you think that about covers it?
paTienT: Yes.
As the patient progresses, the therapist may ask the patient to sum- marize the most important points. Summarizing is much more easily accomplished if the patient has taken good notes during the session:
TherapisT: Okay, Sally, we just have a few minutes left. What do you think is going to be most important for you to remember this week?
You can look at your notes.
Following the final summary, the therapist elicits feedback about the session from the patient.
TherapisT: Okay, Sally, what did you think about the session today?
Was there anything I said that bothered you? Anything you think I got wrong?
paTienT: I am a little bit worried that I could have a setback.
TherapisT: Well, a setback is possible, and if you do find yourself feel- ing significantly worse before our next session, I’d like you to call me and we can discuss whether you should come in sooner. On the other hand, you may very well have another better week.
paTienT: I hope so.
TherapisT: Should we put the topic “setbacks” on the agenda again next week?
paTienT: Yes, I think so.
TherapisT: Anything else about the session? Anything you want us to do differently next time?
paTienT: No, I don’t think so.
TherapisT: Okay. See you next week.
If you sense that patients have not fully expressed their reaction to the session, you may ask them to complete a therapy report (see Figure 5.2). When patients do express negative feedback, you will positively reinforce them and then try to solve the problem. If there is insufficient time to do so, you may apologize and tell patients that you would like to discuss their negative reaction at the very beginning of the following session. Negative feedback usually indicates difficulty in the therapeu- tic alliance (discussed more fully in J. S. Beck, 2005).