Dr. Paul Wong, D.Psyc.(Clinical) SOWK6190/SOWK6127 Cognitive Behavioural Therapy and Cognitive Behavioural Intervention Week 4 - Session two and beyond and the problems with structuring the therapy session Dr. Paul Wong, D.Psyc.(Clinical)

Outline Review of homework Recap of what we have learn This week’s agenda In-class activities Homework

Typical agenda for session 2 and beyond Brief update and check on mood Bridge from previous session Setting the agenda Review of homework Discussion of issues on the agenda, setting new homework, and periodic summaries Final summary and feedback

Goal of 2nd session Help the patient select a problem or goal to focus on; To start solving problems; To reinforce the cognitive model and the identification of automatic thoughts; To continue socializing the patient into cognitive therapy: following the session format, working collaboratively, providing feedback to the therapist, and starting to view her past and ongoing experience in light of the cognitive model.

Brief update and mood check Key: elicits a subjective description from the patient and matches it with objective test scores. Remember, if there are discrepancies, do ask explicitly. “While I am looking at your test scores, tell me how your week went.” “(if client mentions a problem/issue), Should we put this on the agenda?” “Anything else I should know about your week?” Use any opportunity to “educate” your patient about the cognitive model. Why doing mood check again? 1) Demonstrate the therapist’s concerns for how the patient has been feeling in the past week; 2) both the therapist and the patient can monitor how the patient has been progressing over the course of therapy; 3) identify the patient’s explanation for her progress or lack of progress; and 4) reinforce the cognitive model.

Bridge from previous session Key: to check on the patient’s perception and understanding of the previous session that motivates the patient to prepare for the current session by thinking about therapy during the week. You can use the “Session bridging worksheet” (pp.49) to help the client prepare for the next sessions. “what did you get out of the last session? What was important?” “Was there anything about last session that bothered you?” If client forgets, then say, “what could you do this coming week so you’ll remember what we talked about today?” Note: a prime reason for patient’s failure to recall session content is the therapist’s failure to encourage the patient to write down the important points during the session itself.

Setting the agenda Key: the therapist takes more responsibility for agenda setting during early sessions and then gradually shifts responsibility to the patient. It is important for the patient to learn agenda-setting skills so she can contribute with self-therapy after termination. “Okay, so we have already your exam and problem with roommate as your current problems, we have also checked your mood, I’d like to go through your homework and talk more about automatic thoughts. Anything else would you like to set as an agenda for this session?” “(if there are too many things on the agenda), What do you want to focus on today?” Note: if running out of time to go through everything from the agenda, do make such a deviation explicit and elicits the patient's agreement.

Review of homework Key: If the homework is not reviewed, the patient begins to believe that it is not important and compliance with homework drops off dramatically. Please do make sure you have the last session notes with you as well!!!!!!!!!! “what did you get done between the week?” If the client did do the homework, ask why, and go through the homework with her verbally. For beginning therapist – it is easier to adhere to the explicit structure and mark items to be discussed later.

Discussion of issues on the agenda, setting new homework, and periodic summaries Key: since the therapist and the patient develop the agenda together, it is good to ask the patient which item on the agenda she wants to talk about first. This affords the patient the opportunity to be more active and assertive and allows her to take more responsibility. Remember – you are actually doing five things at a time: 1) relate the topic to the patient’s goal; 2) reinforce the cognitive model; 3) continue teaching your patient about automatic thought; 4) provide some symptom relief through helping your client respond to her anxious/depressed thoughts; and 5) as always, maintain and build rapport though accurate understanding. Please read pp.54-58 carefully to have a sense of how these are done thoughtfully.

Feedback Key: In early sessions, the therapist helps the patient to do the summarizing. In later sessions, do ask the patient herself to do it. “we’ve just a few minutes left. Let me summarize what we covered today, and then I’ll ask for your feedback to the session.” If something important comes up from the client, you can say: “maybe we can talk about that more next week, okay?”

Session 3 and beyond Key: Follow the similar structure as used in session two. By there are two major shifts: 1) the patient will be taking more responsibilities in later sessions; and 2) cognitive tasks with shift from automatic thoughts to both automatic thoughts and underlying beliefs. Also, highly recommend that you use the “Therapy Notes” (pp.61) to keep yourself informed about each client. Review them before and fill them up after each session.

Problems with structuring the therapy session

Problems When the therapist becomes aware of a problem, he first specifies it, then conceptualizes why the problem arose, and finally devises a solution that does not disturb the therapeutic alliance.

3 Commonly occur problems Socialization (in terms of therapeutic alliance and CT) Patient’s unwillingness to conform to the prescribed structure because of her perceptions of and dysfunctional beliefs about herself, the therapist, and/or therapy. Difficulty in maintaining the session structure arises because the therapist has imposed the structure in too controlling or demanding a fashion.

Brief Update Patient begins the session with too details an account of or unfocused rambling about her week. T: “Let me interrupt you for a moment… I need a big picture….” T: rephrase “it sounds like you had a hard week….”

Mood Check Patient’s failure to fill out forms, annoyance with forms, or difficulty in subjectively expressing her general mood during the week. Solution – asks the patient whether she remembers and agrees with the rationale for filling them out and determines whether there’s a practical difficulty that needs to be resolved. Check automatic thoughts.

T: “I know you see the forms as irrelevant, but actually they save us time in the therapy session because I don’t have to ask you lost of questions myself”.

Bridge from Previous Session Patient’s difficulty in remembering session content because: She is reluctant to do the homework; and the therapist fails to encourage the patient to jot things done during and after the session.

Setting the Agenda Patient is inadequately socialized or puts a special negative meaning on contributing to the treatment. T: “What problems came up for you this past week/ Or what problems do you expect might come up this week?” T: “What went through your mind when I asked you to set the agenda for the session?”

Setting new homework Therapist: Suggests an assignment that is too difficult or is unrelated to the patient’s concerns; Fails to provide a good rationale; Forgets to review homework assigned during previous sessions; Does not stress the importance of daily homework in general and of specific assignments in particular; Does not explicitly teach the patient how to do the assignment; Does not start the assignment in session or ask standard questions about potential obstacle that might get in the way; does not have the patient write the homework assignment down; or Non-collaboratively sets a homework assignment that the patient not want to do.

Most importantly – Your cognition and attitude about CBT “I can’t structure the session” Patient won’t like the structure” Patient can’t express herself succinctly” “I shouldn’t interrupt her (that will damage the rapport)” “She’ll get mad if I am too directive”.

Homework Since you have some basic knowledge about CT/CBT now, it’s time you can do some preliminary self-reflection about your own attitude and belief about CBT. Please answer this: “Am I suitable to be a CBT therapist? If yes, why? If no, why not?” Do send your answers to me by e-mail. Don’t write an essay, just something very brief is enough!!!