Every so often, I receive the following important question from consumers and potential clients who call our clinic at Beck Institute for Cognitive Behavior Therapy in search of a referral:
"How will I know if I'm getting 'real' CBT?"
I believe it's important for patients to know what to expect in a typical cognitive behavior therapy session, not only so they can assess the treatment they're receiving, but also so they're prepared for therapy and understand and agree with how treatment typically proceeds.
This blog will address one important aspect of CBT: the structure of sessions. Future blogs will address other important aspects, such as the importance of the therapeutic alliance in CBT, basing treatment on a cognitive (and behavioral) understanding of clients' problems, and evaluation of clients' thoughts and beliefs.[1]
Take Jane for example. Even before a session begins, I have Jane (and almost every depressed or anxious patient I see) fill out certain forms to assess her mood, which provide us with an objective method for assessing her symptoms. Then I'll ask Jane to tell me in her own words how she has been feeling this week, compared to other weeks. This is what cognitive behavior therapists call a "mood check," and it's important in deciding what we'll talk about in the session and in making sure that Jane is making progress in treatment.
Next I'll ask Jane to name (but at this point, not to describe) the most important problems she encountered during the week (or that she expects to encounter in the coming week) that she would like my help in solving. This is called "setting the agenda," which allows us to figure out how to best spend our time during today's session. (I may have one or more items for the agenda, too.) Then I'll create a "bridge" between the previous therapy session and this week's therapy session (which may uncover additional agenda problems). I'll ask Jane what happened during the previous week that she thinks I should know about (both positive and negative experiences). I'll also ask her what she thought was important during our last therapy session and we'll discuss the self-help assignments ("homework" or "action plan" items) she did during the week. To finish this initial part of the session, and especially if we have uncovered too many issues to discuss in one session, Jane and I will collaboratively "prioritize the agenda," to decide which items are most important to cover. I make sure it's clear to both of us how Jane would like to spend our time together. (It is important to note that we may collaboratively decide to deviate from our original plan during the session if something else more important arises.)
In the middle part of the session, Jane and I will discuss the problem or problems she put on the agenda. We usually do a combination of problem-solving and assessing the accuracy and usefulness of her thoughts and beliefs in the problematic situation. I'll teach Jane new skills that will help her modify her maladaptive thinking and behavior and solve problems on her own. Throughout the session, I will ask Jane to draw conclusions and summarize important points in her own words -- and she or I will write these therapy notes down. We'll also record her homework in writing, which usually consists of reading therapy notes, implementing solutions to problems (behavior change), responding to her unhelpful or distorted thinking and/or practicing other cognitive and behavioral skills.
At the end of the session, I will ask her for feedback: How did she think the session went? Is there anything that bothered her or that she thought I didn't understand? Is there anything she'd like to see changed in future sessions?
We have found that many therapists say (and believe) that they are delivering CBT but don't adhere to the important structure described above. The essential components of CBT, including structure, are outlined in the manual for the Cognitive Therapy Rating Scale (CTRS). Research has shown that patients have better outcomes when their therapists score highly on this scale (than those whose therapists have low scores). Structure is a very important ingredient in effective CBT treatment.
[1] J. Beck (2011). Cognitive Behavior Therapy: Basics and Beyond, 2nd edition, Guilford Press.
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