1. Introduction
   
2. Cognitive Conceptualization
3. Structure of the First Therapy Session
4. Session Two and Beyond: Structure and Format
5. Problems with Structuring the Therapy Session
6. Identifying Automatic Thoughts
7. Identifying Emotions
8. Evaluating Automatic Thoughts
9. Responding to Automatic Thoughts
10. Identifying and Modifying Intermediate Beliefs
11. Core Beliefs
12. Additional Cognitive and Behavioral Techniques
13. Imagery
14. Homework
15. Termination and Relapse Prevention
16. Treatment Planning
17. Problems in Therapy
18. Progressing as a Cognitive Therapist

A major goal of the cognitive therapist is to make the process of therapy understandable to both therapist and patient. The therapist also seeks to do therapy as efficiently as possible. Adhering to a standard format (as well as teaching the tools of therapy to the patient) facilitates these objectives.

Most patients feel more comfortable when they know what to expect from therapy, when they clearly understand their responsibilities and the responsibilities of their therapist, and when they have a clear expectation of how therapy will proceed, both within a single session and across sessions over the course of treatment. The therapist maximizes the patient's understanding by explaining the structure of sessions and then adhering to that structure.

Experienced therapists who are unaccustomed to setting agendas and structuring sessions as described in this chapter often feel uncomfortable with this fundamental feature of cognitive therapy. Such discomfort is usually associated with negative predictions: The patient will not like it; the patient will feel controlled; it will make me miss important material; it is too rigid. Therapists are urged to test these ideas directly through implementing the structure as specified and noting the results. Therapists who initially feel awkward with a more tightly structured session often find that the process gradually becomes second nature, especially when they note the accompanying results.

The basic elements of a cognitive therapy session are a brief update (including rating of mood and a check on medication compliance, if applicable), a bridge from the previous session, setting the agenda, a review of homework, discussion of issue(s), setting new homework, and summary and feedback. Experienced cognitive therapists may deviate from this format at times, but the novice therapist is usually more effective when he follows the specified structure.

This chapter outlines and illustrates the format of the initial therapy session, whereas the next chapter focuses on the common structure for subsequent sessions. Difficulties in adhering to the structure are described in Chapter 5.

Goals And Structure Of The Initial Session

Preparatory to the first session, the therapist reviews the patient's intake evaluation. A thorough diagnostic examination is essential for planning treatment effectively because the type of Axis I and Axis II disorders (according to DSM) dictates how standard cognitive therapy should be varied for the patient (see Chapter 16). Attention to the patient's presenting problems, current functioning, symptoms, and history helps the therapist to make an initial conceptualization and formulate a general therapy plan. The therapist jots down the agenda items he wishes to cover during an initial session on a therapy notes sheet (see Chapter 4, Figure 4.3).

The following are the therapist's goals for the initial session:

1. Establishing trust and rapport.
2. Socializing the patient into cognitive therapy.
3. Educating the patient about her disorder, about the cognitive model, and about the process of therapy.
4. Normalizing the patient's difficulties and instilling hope.
5. Eliciting (and correcting, if necessary) the patient's expectations for therapy.
6. Gathering additional information about the patient's difficulties.
7. Using this information to develop a goal list.

A recommended structure for the initial session encompassing these goals includes:

1. Setting the agenda (and providing a rationale for doing so).
2. Doing a mood check, including objective scores.
3. Briefly reviewing the presenting problem and obtaining an update (since evaluation).
4. Identifying problems and setting goals.
5. Educating the patient about the cognitive model.
6. Eliciting the patient's expectations for therapy.
7. Educating the patient about her disorder.
8. Setting homework.
9. Providing a summary.
10. Eliciting feedback.

If the patient is taking medication for her psychological problems, if medication is indicated, or if she is currently abusing alcohol or drugs, the therapist also adds these relevant issues to the agenda.

Before describing each session element, a caveat is in order. If the patient is hopeless and suicidal, the goals and format of the first session (or any session) are modified. It is of paramount importance to assess the patient's degree of suicidality, to discover what the patient is so hopeless about, and to undermine her hopelessness (Beck et al., 1979; Fremouw, dePerczel, & Ellis, 1990; Freeman, Pretzer, Fleming, & Simon, 1990). Crisis intervention also takes precedence above all else when the patient is in danger from others or is a potential danger to others.

It is essential to start building trust and rapport with patients in the first session. This ongoing process is easily accomplished with most patients without personality disorders. The therapist whose patient has only a straightforward Axis I diagnosis does not usually need to express his empathy through a large number of direct statements. Instead, he continuously demonstrates his commitment to and understanding of the patient through his words, tone of voice, facial expressions, and body language. Patients feel valued and understood when the therapist demonstrates empathy and accurate comprehension of their problems and ideas through his thoughtful questions and statements.

The therapist's implicit and sometimes explicit messages are that he cares about and values the patient; that he is confident they can work together; that he believes he can help her and that she can learn to help herself; that he really wants to understand what she's experiencing and what it's like "to walk in her shoes"; that he's not overwhelmed by her problems, even though she might be; that he has seen and helped other patients much like her; and that he believes cognitive therapy is the appropriate treatment for her and that she will get better.

As a further way of demonstrating respect for and collaboration with the patient, the therapist checks on the patient's perception of the therapeutic process and of himself as a therapist at the end of each session. Asking for explicit feedback helps strengthen the therapeutic alliance. Eliciting the patient's feedback enables the therapist to assess whether he is coming across as empathic, competent, and caring and affords him the opportunity to correct at an early stage any misperceptions the patient has. Patients often appreciate the rare invitation to give feedback to a professional; they receive a positive message about their partnership in therapy and ability to affect the therapeutic process. At times, a therapist and patient have a different perspective on what occurred in a therapy session; the likelihood of having the opportunity to explore these important moments is increased if the therapist consistently elicits the patient's feedback in a nonperfunctory, nondefensive manner.

Setting The Agenda

As mentioned previously, an important objective in the first session is to begin to socialize the patient to cognitive therapy. As with other techniques, it is advisable first to provide the patient with a brief rationale.

Therapist: I'd like to start off our session by setting the agenda--deciding what we'll talk about today. We'll do this at the beginning of every session so we make sure we have time to cover the most important things. I have some items I'd like to suggest and then I'll ask you what you'd like to add. Is that okay?

Patient: Yeah.

T: Our first session will be a little different from future sessions, because we have a lot of ground to cover and we need to get to know each other better. First, I'd like to check on how you've been feeling. Then I'd like to hear more about what brought you to therapy, what you'd like to accomplish and what some of your problems are, and what you expect from therapy. Okay so far?

P: Uh huh.

T: I'd also like to find out what you already know about cognitive therapy, and I'll explain how our therapy will go. We'll talk about what you might try for homework, and at the end, I'll summarize what we've talked about and ask you for feedback--how you thought therapy went....Is there anything you want to add to the agenda today?

P: Yes. I have some questions about my diagnosis and how long you expect I'll need to be in therapy.

T: Fine. Let me jot down your questions, and we'll make sure to get to them today. (Jotting patient's items.) You'll notice that I tend to write down a lot of things during our session. I want to make sure to remember what's important....Okay, anything else for the agenda today?

P: No, that's all.

T: If you think of other things as we go along, just let me know. Ideally, setting the agenda is quick and to the point. Explaining the rationale makes the process of therapy more understandable to the patient and elicits her active participation in a structured, productive way. Failure to set explicit agendas frequently results in at least some unproductive discourse as it hinders the therapist and patient from focusing on the issues that are of greatest importance to the patient. The therapist refers to agenda setting again toward the end of the session when he reviews the patient's homework. One homework assignment will be for the patient to think about (and perhaps jot down) the topic name (rather than a lengthy description) of a situation or problem she wants to put on the agenda for the next session. Most patients easily learn how to contribute to the agenda. Chapter 5 describes strategies to try when agenda setting is problematic.

Mood Check

Having set the agenda in this initial session, the therapist does a brief mood check. In addition to her weekly subjective report, objective self-report questionnaires such as the Beck Depression Inventory, Beck Anxiety Inventory, and Beck Hopelessness Scale (see Appendix D) help the patient and therapist keep objective track of how the patient is doing. Careful examination of these tests can highlight for the therapist problems that the patient may not have reported verbally, for example, difficulties sleeping, decrease in sexual drive, feeling like a failure, and increased irritability.

If objective tests are unavailable, the therapist may choose to spend some time in the first session teaching the patient to provide a rating of her mood on a 0-100 scale. ("Thinking back over the past week, on the average, how has your depression [or anxiety or anger, if these are the presenting problems] been on a 0-100 scale, 0 meaning no depression at all and 100 meaning the most depressed you've ever felt?") In the transcript that follows, the therapist has finished setting the agenda and is in the process of assessing the patient's mood. T: Okay, next. How about if we start with how you've been doing this week. Can I see the forms you filled out? (Looks them over.) It seems as if you're still pretty depressed and anxious; these scores haven't changed much since the evaluation. Does that seem right?

P: Yes, I guess I'm still feeling pretty much the same.

T: (Giving rationale.) If it's okay with you, I'd like you to come to every session a few minutes early so you can fill out these three forms. They help give me a quick idea of how you've been feeling in the past week, although I'll always want you to describe how you've been doing in your own words, too. Is that okay with you?

P: Sure.

The therapist notes the summed score of objective tests and also quickly scans individual items to determine whether the tests point out anything important for the agenda, especially noting items related to hopelessness and suicidality. He may also graph test scores or the 0-100 ratings to make the patient's progress evident to them both (see Figure 3.1).

If the patient resists filling out forms, the therapist adds this problem to the agenda so he can help her identify and evaluate her automatic thoughts about completing forms. If need be, he negotiates with the patient, perhaps settling for 0-100 ratings or low/medium/high severity ratings in order to maintain their collaboration (see Chapter 5).

Review Of Presenting Problem, Problem Identification, And Goal Setting

In the next section, the therapist briefly reviews the patient's presenting problem. He asks the patient to bring him up-to-date, then turns their attention to identifying the patient's specific problems. As a logical extension, he then helps the patient turn these problems into goals to work on in therapy.

T: (Summarizing first.) Okay, we've set the agenda and checked on your mood. Now, if it's okay, I'd like to make sure I understand why you've come for therapy. I've read through the initial intake summary, and it looks as if you became pretty depressed about 4 months ago, shortly after you came to college. And you've also had a lot of anxiety, but that's not as bad as the depression. Is that right?

P: Yeah ... I've been feeling pretty bad.

T: Anything important happen between when you were evaluated and now that I should know about?

P: No, not really. Things are pretty much the same.

T: Can you tell me specifically what problems you've been having? It helps me to hear it in your own words.

P: Oh, I don't know. Everything is such a mess. I'm doing terribly at school. I'm way behind. I feel so tired and down all the time. I feel sometimes like I should just give up.

T: Have you had any thoughts of harming yourself?

[The therapist gently probes for suicidal ideation because he will focus directly on the patient's hopelessness if the patient is actively suicidal.]

P: No, not really. I just wish all my problems would somehow go away.

T: It sounds like you're feeling overwhelmed?

P: Yes, I don't know what to do.

T: (Helping the patient to focus and to break down the problems into a more manageable size.) Okay, it sounds like you have two major problems right now. One is that you're not doing well at school. The other is that you feel so tired and down. Are there any others?

P: (Shrugs her shoulders.)

T: Well, what would you like to accomplish in therapy? How would you like your life to be different?

P: I'd like to be happier, feel better.

T: (Getting the patient to specify in behavioral terms what "happier" and "feeling better" are for her.) And if you were happier and feeling better, what would you be doing?

P: I'd like to be doing better in my courses and keeping up with the work ... I'd be meeting more people, maybe getting involved in some activities, like I was in high school ... I guess I wouldn't be worrying all the time. I'd have some fun and not feel so lonely.

T: (Getting the patient to participate more actively in the goal-setting process.) Okay, these are all good goals. How about if we have you write them on this no-carbon-required paper so we can each keep a copy.

P: All right. What should I write?

T: Here, date it at the top and write "Goal List." ... Now what was one goal? (Guiding the patient in writing the following list with items expressed in behavioral terms.)

Goal List-February 1
1. Improve School Work.
2. Decrease worrying about tests.
3. Meet more people.
4. Join school activities.

T: Okay, good. Now, how about for homework if you read through this list and see if you have any other goals to add. All right?

P: Yes.

T: Well, before we go on, let me just quickly summarize what we've done so far. We've set the agenda, reviewed your forms, talked about why you came for therapy and started a goal list. The therapist efficiently reviews the patient's presenting problem, determines that the patient is not at risk for suicide and that there have been no significant developments since the initial intake evaluation, and helps the patient translate specific problems into goals for therapy. If the patient had been at risk for suicide, had important new information to impart, or had difficulty specifying her problems or goals, the therapist would have spent more time in this phase of the initial session (but would, of course, have had less time for other items).

Early in the session, the therapist gets the patient more actively involved by writing. He suggests to her what to write, as it is not obvious to her. (In every session, he will ask her to take notes on no-carbon-required paper [available in office supply stores] or in a notebook [from which he can photocopy] so that both he and the patient can keep a copy.) The therapist himself does the writing for patients who cannot or strongly prefer not to write themselves. Patients, including children, who are not literate can draw pictures or listen to an audiotape of the therapy session as a way of reinforcing key therapy ideas.

The therapist also guides the patient to specify a global goal ("I'd like to be happier, feel better") in behavioral terms. Rather than allowing a discussion of goals to dominate the session, he asks the patient to refine the list for homework. Finally, he summarizes what they have discussed so far in the session before moving on.

Educating The Patient About The Cognitive Model

An important overarching goal of cognitive therapy is to teach the patient to become her own cognitive therapist. Early on, the therapist elicits (and corrects, if necessary) what the patient already knows about this kind of therapy. He educates her about the cognitive model, using her own examples, and gives her a preview of therapy.

T: How about if we turn to finding out what you already know about cognitive therapy and how you expect therapy to proceed.

P: Well, I don't really know much about it, just what the counselor said.

T: What did you learn?

P: To tell you the truth, I don't really remember.

T: That's okay, we'll go over some of the ideas now. First I'd like to find out how your thinking affects how you feel. Can you think of any time in the past few days when you noticed your mood change? When you were aware that you had become particularly upset or distressed?

P: I think so.

T: Can you tell me a little about it?

P: I was having lunch with a couple of people I know and I started to feel a little nervous. They were talking about something the professor had said in our course that I didn't understand.

T: When they were talking about what the professor said, just before you began to feel nervous, do you remember what was going through your mind?

P: I was thinking that I didn't understand but I couldn't let them know it.

T: (Using the patient's precise words.) So you had the thoughts, "I don't understand" and "I can't let them know?"

P: Yeah.

T: And that made you feel nervous?

P: Yeah.

T: Okay, how about if we make a diagram. You just gave a good example of how your thoughts influence your emotion. (Guides the patient in writing down the diagram in Figure 3.2 and reviews it with her.) Is that clear to you? How you viewed this situation led to a thought which then influenced how you felt.

P: I think so.

T: Let's see if we can gather a couple more examples from the past few days. For example, how were you feeling when you were in the waiting room today, before our appointment?

P: Kind of sad.

T: And what was going through your mind at the time?

P: I don't remember exactly.

T: (Trying to make the experience more vivid in the patient's mind.) Can you imagine yourself back in the waiting room right now? Can you imagine sitting there? Describe the scene for me as if it's happening right now.

P: Well, I'm sitting in the chair near the door, away from the receptionist. A woman comes in, she's looking kind of smiley, and she talks to the receptionist. She's joking and looking happy and ... normal.

T: And how are you feeling?

P: Sad.

T: What's going through your mind?

P: She's happy. She's not depressed. I'll never be like that again.

T: (Reinforcing the cognitive model.) Okay. Again we have an example of how what you were thinking--"I'll never be like that again"--influenced how you felt; it made you sad. Is this clear to you?

P: Yeah. I think so.

T: Can you tell me in your own words about the connection between thoughts and feelings? (Making sure the patient can verbalize her understanding of the cognitive model.)

P: Well, it seems that my thoughts affect how I feel.

T: Yes, that's right. What I'd like you to do, if you agree, is to keep track this coming week of what's going through your mind when you notice your mood changing or getting worse. Okay? (Facilitating the patient's carrying through the work of the therapy session throughout the week.)

P: Uh huh.

T: In fact, how about if you write this assignment down [on no-carbon-required paper] so we both have a copy. "When I notice my mood changing or getting worse, ask: `What's going through my mind?' and jot down the thoughts." Now, do you have an idea why I'd like you to jot them down?

P: I guess it's because you're saying that my thoughts make me feel bad.

T: Or they at least contribute to your feeling bad, yes. And to give you a preview of cognitive therapy--part of what we'll be doing together is identifying these thoughts which seem to be upsetting you. Then we'll examine those thoughts and see how accurate they are. Lots of times I think we'll find that these thoughts are not completely accurate. We should have you write down something about that, too.

P: (Does so.)

T: So we'll evaluate the thoughts and you'll learn to change your thinking.

P: That sounds hard.

T: Well, a lot of people think that at first, but pretty soon they find they get good at it. We'll just go step by step to teach you how to do it. But it was good that you identified your thought. Make sure if you do have any more thoughts like, "That sounds hard," to write them down so we can look at them next session. Okay?

P: Okay.

T: Do you think you'll have any trouble jotting down some thoughts? (Checking to see if the patient anticipates difficulties that they could problem-solve.)

P: No. I think I'll be able to.

T: Good. But even if you can't, that's okay. You'll come back next week and we'll work on it together. All right?

P: Sure.

In this section, the therapist explains, illustrates, and records the cognitive model with the patient's own examples. He tries to limit his explanations to just a couple of sentences at a time and asks the patient to put into her own words what he has said so he can check on her understanding. (Had the patient's cognitive abilities been impaired or limited, the therapist might have used more concrete learning aids such as faces with various expressions to illustrate emotions.) He also makes sure that the patient writes down the most important points.

This particular patient easily grasps the cognitive model. Had she experienced difficulty in identifying her thoughts or emotions, her therapist would have weighed the benefits of using other techniques (see Chapter 6) to accomplish this objective with the possible consequence of pushing too hard (perhaps increasing the patient's dysphoria or interfering with rapport). Had he decided against further explication of the cognitive model, he would take care not to have the patient blame herself for failing to catch on. ("It's sometimes hard to figure out these thoughts. Usually they're so quick. It's no big deal. We'll come back to it another time.")

In the next section, the therapist probes for automatic thoughts in the form of visual images. Patients tend to have much more difficulty identifying these visual automatic thoughts and may not be able to provide examples. Nevertheless, they are much more likely to recognize and report images if they are alerted to them early in therapy.

T: Now, let me mention one more thing. Did you notice that I said you should ask yourself what is going through your mind when your mood changes, not "What am I thinking?" The reason I phrased it that way was because we often think in images or in picture form. For example, before you came in for the first time today, did you imagine what I might look like?

P: I think I had a vague picture of someone older and maybe more stern or more serious.

T: Okay, good. That picture or imagining is what we call an image. So when you ask yourself, "What's going through my mind?" check for both words and images. Do you want to write that down, too? In this way, the therapist socializes the patient into recognizing that automatic thoughts may come in many different forms and even different sensory modalities, increasing the likelihood that she will be more readily aware of her automatic thoughts in whatever form they occur.

Expectations For Therapy

Patients often enter therapy with the notion that therapy is mystical or unfathomable and that they will not be able to comprehend the process by which they will get better. The cognitive therapist, in contrast, stresses that this kind of therapy is orderly and rational and that patients get better because they understand themselves better, solve problems, and learn tools they can apply themselves. The therapist continues to socialize the patient into therapy by imparting the message that the patient is to share responsibility for making progress in therapy. For most patients, a brief discussion, such as the one below, suffices.

T: Next I'd like to find out how you expect to get better.

P: I'm not sure what you mean.

T: Well, some patients have the idea that a therapist will cure them. Others think that they'll get better with the therapist's help but they have a sense that they are the ones who really will be doing the work.

P: I guess before I came in I thought you would somehow cure me. But from what you've said today, I guess you'll teach me things to do.

T: That's right. I'll help you learn the tools to get over the depression--and, in fact, you'll be able to use these tools for the rest of your life to help with other problems.

At the initial session, it is desirable for the therapist to give the patient a general sense of how long she should expect to remain in therapy. Usually it is best to suggest a range, 1 1/2 to 4 months for many patients, though some might be able to terminate sooner (or might have to, due to financial constraints or insurance limitations). Other patients, particularly those with chronic psychological difficulties or those who want to work on problems related to a personality disorder, may remain in therapy for a year or more. Most patients progress satisfactorily with weekly sessions unless they are severely depressed or anxious, suicidal, or clearly in need of more support. Toward the end of therapy, sessions may be gradually spaced further apart to give the patient more opportunity to solve problems, make decisions, and use her therapy tools independently.

The next example presents one way in which the therapist might give the patient an idea of how therapy will proceed:

T: If it's okay with you, we'll plan to meet once a week until you're feeling significantly better, then we'll move to once every 2 weeks, then maybe once every 3 or 4 weeks. We'll make these decisions about how to space out therapy together. Even when we decide to terminate, I'll recommend that you come back for a "booster" once every few months for a while. How does that sound?

P: Fine.

T: It's hard to predict now how long you should be in therapy. My best guess is somewhere around 8 to 14 sessions. If we find that you have some real long-standing problems that you want to work on, it could take longer. Again, we'll decide together what seems to be best. Okay? Educating The Patient About Her Disorder

Most patients want to know their general diagnosis, that they are not crazy, and that their therapist has helped others like them before and does not think they are strange. Usually it is preferable to avoid the label of a personality disorder diagnosis. Instead it is better to say something more general and jargon free, such as, "It looks as if you've been pretty depressed for the last year and you've had some long-standing problems with relationships." It is also desirable to give the patient some initial information about her disorder so she can start attributing some of her problems to her disorder and thereby decrease self-criticism.

The following transcript illustrates how to educate patients who are depressed. (It requires alteration, of course, for patients with other disorders.)

T: Now the last thing on our agenda was your diagnosis. The evaluation shows that you are significantly depressed and anxious--as are many patients we see here. I'm quite hopeful that we'll be able to help you feel better. What do you think?

P: I was afraid you'd think I was crazy.

T: Not at all, you have a fairly common illness or problem called depression, and it sounds as though you have a lot of the same problems as most of our patients here. But again, that's a good automatic thought, "You'll think I'm crazy." How do you feel now that you've found out it isn't true?

P: Relieved.

T: So correcting your thinking did help. If you have any more thoughts like that, would you write them down for homework so we can evaluate them at our next session?

P: Sure.

T: This kind of very negative thinking is one symptom of your depression. Depression affects how you see yourself, your world, and your future. For most people who are depressed, it's as if they're seeing themselves and their worlds through eyeglasses covered with black paint. Everything looks black and hopeless. Part of what we'll do in therapy is to scrape off the black paint and help you see things more realistically.... Does that analogy make sense to you?

[Using an analogy often helps the patient to see her situation in a different way.]

P: Yeah. I understand.

T: Okay, let's go over some of the other symptoms of depression that you have, too. The depression interferes with your appetite, your sleep, your sexual desire and your energy. It also affects your motivation and drive, among other things. Now most depressed people start criticizing themselves for not being the same as they had been before. Do you remember any recent times you've criticized yourself? (Eliciting specific incidents.)

P: Sure. Lately I've been getting out of bed late and not getting my work done and I think I'm lazy and no good.

T: Now if you had pneumonia and had trouble getting out of bed and getting everything done, would you call yourself lazy and no good?

P: No, I guess not.

T: Would it help this week if you answered back the thought, "I'm lazy"?

P: Probably. I might not feel so bad.

T: What could you remind yourself?

[Eliciting a response rather than just providing one fosters active participation and a degree of autonomy.]

P: I guess that I am depressed and it's harder for me to do things, just like if I had pneumonia.

T: Good. And remind yourself that as you work in therapy and your depression lifts, things will get easier. Would you be willing to write something down about this so you'll remember it this week? (Being collaborative, yet strongly giving the message that the patient is expected to participate actively in the session and to review session content between sessions.)

P: Yeah.

T: And here's a booklet for you to read [Coping with Depression; see Appendix D] that tells you more about depression.

End-Of-Session Summary And Setting Of Homework

Like the capsule summaries (see p. 58) the therapist makes throughout the session, the final summary ties together the threads of the session and reinforces important points. The summary also includes a review of what the patient agreed to do for homework. In the early sessions, the therapist summarizes; as therapy progresses, the therapist encourages the patient to summarize.

T: Well, let me summarize what we talked about today. We set the agenda, checked your mood, set some goals, and explained how your thoughts influence your feelings. We talked about how therapy will go. We're going to be doing two major things: working on your problems and goals and changing your thinking when you find it's not accurate. Now let's see what you've written down for homework. I want to make sure you think it's manageable and that it'll help.

Homework-February 1
1. Refine goal list.
2. When my mood changes, ask myself, "What's going through my mind right now?" and jot down thoughts (and images). Remind myself that these thoughts may or may not be true.
3. Remind myself that I'm depressed right now, not lazy, and that's why things are hard.
4. Think about what I want to put on the agenda next week (what problems or situation) and how to name it.
5. Read booklet and therapy notes.
6. Go swimming or running three times this week.

The therapist seeks to ensure that the patient experiences success in doing therapy homework (see Chapter 14). If he senses that the patient may not carry out any part of the assignment, he offers to withdraw it. ("Do you think you'll have trouble jotting down your thoughts? [If yes,] do you think we should cross it off the list for today? It's no big deal, one way or the other.")

Occasionally a patient bristles at the term "homework." The therapist then takes care to differentiate therapy homework, which is collaboratively set and especially designed to help the patient feel better, from previous experiences (usually school homework) which involved mandatory, unpersonalized, often unhelpful assignments. Therapist and patient can also brainstorm to find a more acceptable term such as "self-help activities." Having solved the practical problem of using the term "homework," the therapist might pursue (or mentally file away for future exploration) the meaning to the patient of the word "homework" to discover whether her objection to it fits into a larger pattern (e.g., Is she sensitive to control by others? Does she feel inadequate when asked to do a task?).

A common first-session (and later-session) homework assignment involves bibliotherapy. The therapist might ask the patient to read a chapter from a layman's book on cognitive therapy (e.g., Burns, 1980, 1989; Greenberger & Padesky, 1995; Morse, Morse, & Nackoul, 1992) or an educational brochure (see Appendix D). He tries to get the patient to become actively involved in the reading ("When you read this, mark it up so you can tell me what you agree with or disagree with, what seems to fit you and what doesn't").

A second common homework assignment in early sessions is activity monitoring and/or scheduling (see Chapter 12). The goal is to get patients to resume activities in which they had previously gained a sense of accomplishment and/or pleasure.

Feedback

The final element of every therapy session is feedback. By the end of the first session, most patients feel positively about the therapist and the therapy. Asking for feedback further strengthens rapport, providing the message that the therapist cares about what the patient thinks. It also gives the patient a chance to express, and the therapist to resolve, any misunderstandings. Occasionally a patient makes an idiosyncratic interpretation of something the therapist said or did. Asking the patient whether there was anything that bothered her gives her the opportunity to state and then to test her conclusions. In addition to verbal feedback, the therapist may have the patient complete a written Therapy Report.

T: Now at the end of each session, I'm going to ask for feedback about how you felt the session went. You actually get two chances--telling me directly and/or writing it on a Therapy Report which you can fill out in the waiting room after our session. I'll read it over, and if there are any problems, we can put them on the agenda at our next session. Now, was there anything about this session that bothered you?

P: No, it was good.

T: Anything important that stands out?

P: I guess that maybe I can feel better by looking at what I'm thinking.

T: Good. Anything else you'd like to say or anything you'd like to put on the agenda for next session?

P: No.

T: Okay then. It was a pleasure working with you today. Would you please fill out the Therapy Report in the waiting room now and the other three forms I gave you just before our session next week? And you'll try to do the homework you wrote down on your homework sheet. Okay?

P: (Nods.) Okay. Thanks.

T: See you next week.

Occasionally, a patient does have a negative reaction to the first therapy session. The therapist tries to specify the problem and establish its meaning to the patient. Then he intervenes and/or marks the problem for intervention at the next session, as in the following example:

T: Now, was there anything about this session that bothered you?

P: I don't know ... I'm not sure this therapy is for me.

T: You don't think it'll help?

P: No, not really. You see, I've got real-life problems. It's not just my thinking.

T: I'm glad you told me. This gives me the opportunity to say that I do believe that you have real-life problems. I didn't mean to imply that you don't. The problems with your boss and your neighbors and your feelings of loneliness.... Of course, those are all real problems; problems we'll work together to solve. I don't think that all we need to do is look at your thoughts. I'm sorry if I gave you that impression.

P: That's okay....It's just, like...well, I feel so overwhelmed. I don't know what do to.

T: Are you willing to come back next week so we can work on the overwhelmed feelings together?

P: Yeah, I guess so.

T: Is the homework contributing to the overwhelmed feeling, too?

P: ...Maybe.

T: How would you like to leave it? We could just decide now for you not to do homework this week and we'll do it together at our next session instead. Or you could take this sheet home and decide at home if you're feeling up to doing it.

P: I'd just feel guilty if I brought it home and didn't do it.

T: Okay, then let's plan for you not to do it. Anything else that bothered you about today's session?

Here the therapist recognizes the necessity for strengthening the therapeutic alliance. Either he missed signs of the patient's dissatisfaction during the session or the patient was adept at concealing it. Had the therapist failed to ask for feedback about the session or been less adept at dealing with the negative feedback, it is possible that the patient would not have returned for another session. The therapist's flexibility about the homework assignment helps the patient reexamine her misgivings about the appropriateness of cognitive therapy. By responding to feedback and making reasonable adjustments, the therapist demonstrates his understanding of and empathy toward the patient, which facilitates collaboration and trust.

The therapist will make sure to express at the beginning of the next session how important it is to him that they work as a team to tailor the therapy and the homework so the patient finds them helpful. The therapist also uses this difficulty as an opportunity to refine his conceptualization of the patient. In the future, he does not abandon homework altogether but ensures that it is more collaboratively set and that the patient does not feel overwhelmed.

Summary

The initial therapy session has several important goals: establishing rapport; refining the conceptualization; socializing the patient to the process and structure of cognitive therapy; educating the patient about the cognitive model and about her disorder; and providing hope and some symptom relief. Developing a solid therapeutic alliance and encouraging the patient to join with the therapist to accomplish therapeutic goals are of primary importance in this session. The next chapter describes the structure of later therapy sessions and Chapter 5 deals with difficulties in structuring sessions.

Copyright © 1995, Guilford Publications, Inc. This excerpt is posted with permission of Guilford Publications, Inc. and is subject to copyright law and restricted from further use. No part of this excerpt may be reproduced, stored in a retrieval system or transmitted in any form or by any means (electronic, photocopying, recording or otherwise) without prior written permission of the publisher. To obtain permission please contact Guilford Publications, Inc. at the address below or e-mail: kathy.kuehl@guilford.com

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