The Structure Of A Typical Session

Although the content of CT for depression varies dramatically from patient to patient, the process of therapy is relatively similar. Sessions typically last 50 minutes and are scheduled on a weekly basis, although it is not uncommon at the beginning of the treatment process (i.e., the first 3 or 4 weeks) to schedule two sessions a week for more severely depressed patients. Session scheduling and session time frames can be used flexibly, though. With more depressed patients, it may be more productive to have relatively shorter sessions more frequently at the beginning of treatment, then move toward a weekly schedule of sessions as the depression begins to lift. Also, it is fairly common for the assignments between one session and the next to become somewhat more elaborate and to need time for implementation as the treatment develops. In such a case, it may be that scheduling sessions too frequently does not permit the patient enough time to complete homework, and may be somewhat unproductive. Clinical judgment is required to ensure that sessions are frequent enough that positive momentum is maintained, but not so frequent that the patient feels that the steps between one session and the next are too small, or that therapy is too slow. Of course, issues such as holidays, financial considerations, or the limits imposed on therapy by managed care or insurance repayment programs, can also place restrictions on the ability to have regular sessions. Because of these practical considerations, it is important at the outset of treatment to discuss with the patient the approximate length of time that treatment takes (20-24 sessions in research trials, for outpatient depression), as well as the costs associated with treatment.

A typical CT session can be conceptualized as having three phases: a beginning, the "work," and wrapping up. Each part is discussed below, although it should be noted that the therapist might move forward or backward across these phases, if indicated. For example, one part of the beginning of each session is to set the agenda—to identify the topics to be discussed that session—before actually dealing with each in turn. Sometimes it turns out that a given topic is larger than anticipated at the beginning of the session, however, so therapist and patient should both feel comfortable renegotiating the agenda, if it becomes clear that it is not manageable within the available time frame.

The beginning part of a CT session itself has several components. Particularly in the earliest phases of CT for depression, therapists typically have patients complete a depression inventory, such as the Beck Depression Inventory—Second Edition (BDI-II; Beck, Steer, & Garbin, 1988); see also Nezu et al., 2000) prior to the start of the session. Thus, the beginning of the session consists of a check-in on functioning. Significant symptom changes are noted, and the causes of these changes might form part of the content of the session agenda, if it seems helpful. Indeed, cognitive therapists often capitalize on happenstance events that have a dramatic effect on the patient's functioning (negative and positive), because understanding these events helps them to develop the case conceptualization, to teach the CT model to the patient, to introduce new techniques, to develop the collaborative relationship, or simply to encourage to reflection about progress made during treatment.

In addition to the use of a questionnaire, CT therapists typically conduct a "mood check" with their patients, which comprises a 0- to 100-point rating of depression, with 0 as Best ever, and 100 as Most depressed ever. The mood check is a very "quick and dirty" assessment device, but it can be used to track mood across time, even within sessions. Also recommended, especially in the early stages of treatment for depression, is regular assessment of possible hopelessness and suicidality. If the therapist uses BDI-II as a presession measure, items 2 (pessimism) and 9 (suicidal thoughts or wishes) may be quickly reviewed to look for changes on these dimensions. Cognitive therapists who work with depressed patients should know not only local laws and ethical requirements about suicide but also the risk factors for suicidality, how to assess suicide risk, and how to use available resources effectively to mitigate suicide risk.

Following a brief review of the patient's functioning, and in the absence of a suicidal crisis that may warrant attention in its own right, the next part of the beginning phase of a CT session most often deals with the homework. General success or problems with the assigned homework are reviewed, and the lessons learned may be briefly stated, or the assignment itself might be put on the agenda for further discussion. Certainly, if the homework was not completed, if there were major problems with its implementation, or if there was a major benefit from the homework, it is likely to be put on the formal agenda.

The therapist also inquires whether the patient has brought any particular issue to the session that he/she wants to discuss. This issue might be something learned over the course of therapy, a recent difficulty, or an impending problem. The issue is named, then put on the list of agenda topics. In addition, the therapist may have items that he/she wants to put on the agenda. For example, it may be an appropriate point in the course of therapy for the therapist to introduce a particular technique, and if so, the therapist can introduce this idea at the beginning of the session and formally ask to schedule part of the session for this purpose.

Having identified the possible topics for the agenda, the therapist typically briefly reviews the list out loud, and asks the patient whether the agenda is reasonable for the time available. If not, it may be necessary either to limit discussion of some topics purposely or to drop them from the agenda completely for that session, to permit more time for more important topics. Generally, about two or three items is a good limit for a single session. A topic eliminated from one session is most often carried over to the next session, when the therapist asks the patient if it is a continuing concern. A common strategy used by cognitive therapists is to ask the patient for his/ her perception of the most important topic in terms of reducing depression, and to start with that topic. Other topics can be similarly ordered by importance. General principles demonstrated through this strategy include spending the most time where there is likely maximal benefit, working on issues of high import to the patient, and collaboration between therapist and patient.

The second phase of a CT session consists of "the work." This phase involves turning to each agenda item in sequence, examining the issues/ problems that are present, and using CT techniques to help the patient to understand better the dynamics of the problem, and to try to overcome the problem. The therapist needs to transition from an assessment mode as each new topic is introduced and discussed, to an intervention mode, once some useful technique becomes apparent. Knowing what to ask about and how to collect useful assessment information are skills that requires considerable experience, just as knowing when to stop the assessment and start the intervention is a matter of skill and practice. Furthermore, a wide range of techniques can, in principle, be employed in CT, and the skillful selection of techniques is perhaps one of the most challenging aspects of CT. Doing all of these things, while fostering a collaborative and efficient working therapeutic relationship, is a complex endeavor that requires considerable interpersonal skill, knowledge of the CT model, training, and experience.

The actual content of "the work" phase of a CT varies depending on the patient's level of depression; his/her progress in treatment; the case conceptualization; and the presence of acute stressors, comorbid problems, and other factors. Examples of typical content in CT for depression are offered below. From a process perspective, though, it is important to note that as each content issue is discussed, and as therapist and patient come to some resolution, they will most often work together to develop a homework assignment in which the patient implements the ideas discussed in the session in his/her actual life. Important questions for the therapist to consider when assigning homework follow:

1. Is the general nature and purpose of the homework clear to both the therapist and patient?

2. Is the homework planned for a specific time and place?

3. Will it be obvious when the homework is/is not completed?

4. Have possible deterrents or impediments to completing the homework been evaluated and problem-solved, if necessary?

5. Did the patient make an active commitment to attempt the homework?

6. Are the expected benefits of the homework clear to both patient and therapist? (Kazantzis et al., 2005).

Towards the end of the session, the therapist should note that time is winding down (or that the issues put on the agenda have been discussed). With the patient's participation, he/she should review the entire session, including the main themes, as well as the specific homework assignments that have emerged. The therapist may invite the patient to summarize the session, because this process both involves the patient and helps the therapist to ensure that what he/she sees as the key elements are appreciated by the patient. Such reviews can sometimes also identify that the patient has misconstrued or reinterpreted the work done in the session, and so provides an opportunity for the therapist not only to use this information in the case conceptualization but also to correct these misperceptions. For example, if a patient failed to do homework, and the therapist includes the homework on the agenda and further inquires at length about the patient's reasons for not completing the homework, it is possible that in the session review the patient may have the idea, "You are disappointed with me because I didn't do my homework." The therapist may use this type of misunderstanding (assuming the therapist is in fact not disappointed) to find out whether he/ she did something to signal such a reaction to the patient, whether the patient is oversensitive to the issue of criticism, or to show how the patient tends to perceive disappointment or rejection from others based on minimal information.

Sometimes the summary and homework review reveal that the plan is too ambitious. In such cases it is better to reduce the overall homework to maximize the chances for successful completion of those items that are left on the list (Detweiler & Whisman, 1999). One way to accomplish this goal is to keep certain key issues as homework, but place everything else in a "bonus" category, that is clearly conceptualized as extra, and not part of the key homework. It is also often a good idea to have the homework written down, because this action reinforces the activities to the patient. Other benefits of writing include the ability to make sure the homework is clearly understood and to serve as a memory aid to the patient between sessions. Homework can be recorded in lots of different ways, including on index cards, on sheets of paper, on Post-it notes, in a binder, on an electronic organizer, in a computer file, on a voice recorder, or in a therapy notebook. The therapist should ask the patient about his/her preferred method, because it is the one that maximizes chances for him/her to attempt the homework. The therapist should also record the homework in his/her therapy notes, to be able to inquire about this aspect of therapy at the beginning of the next session.

Before the patient leaves, it is helpful to ask briefly if he/she has any other reactions to the session. A positive predictor of treatment response in CT for depression is early completion of homework (Burns & Nolen-Hoeksema, 1991), so if the patient expresses some enthusiasm for attempting the homework, the therapist can reinforce this reaction. Patient reactions to sessions may also be used to gauge whether any therapy relationship issues need to be addressed in future sessions. For example, a recent patient of mine indicated that she was "a control freak" and wanted to be in charge of most relationships. Being in a potentially "one down" position as patient was a challenge to her sense of autonomy and control, so I was careful to involve her fully in all major decisions. Even so, the patient reported discomfort with therapy at the end of one session, because she felt "stupid" and "incompetent" learning about new ways to approach her life issues. This report helped me to build the case conceptualization and also allowed us to discuss the issue openly, and circumvent a potential impediment to treatment.

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