CBT Structure & Format; Quantified Measures Flashcards
Rationale for Emphasizing Structure in CBT
- Increases Efficiency
- Comforting to Many Clients
- Promotes Active Participation & Collaboration
- Contributes to Generalization & Independence
- CBT Structure – Linked to Better Treatment Outcome
Overarching Therapy Structure
• Therapy Overall Is Divided Into Three Phases:
o Beginning Phase
o Middle Phase
o End Phase
Beginning Phase:
• Goals
o Build therapeutic alliance
o Gather information pertaining to presenting problem(s) and client background
o Identify & specify treatment goals
o Socialize client to the cognitive model
o Educate client about diagnosis (if applicable)
o Formulate & share case conceptualization
• Therapist generally takes the lead
• Treatment tends to be more educative and behavioral
Middle Phase:
• Beginning phase work continues
• Focus moves primarily to cognitive interventions
o Emphasis is on identifying, evaluating, and modifying thoughts and beliefs
o Focus may shift from automatic thoughts to deeper beliefs as treatment progresses
• Skill Building
o E.g. relaxation, assertion, problem-solving, time management
End Phase:
- Focus is on preparing for termination and preventing relapse
- Client takes a more active role in therapy
- Taper frequency of sessions
Structure of Individual Sessions:
- Brief Update
- Feedback on Previous Session
- Agenda Setting
- Homework Review
- Discussion of Agenda Item(s)
- Devise & Assign Homework
- Summary & Feedback
Brief Update
• Quick review of any significant events or changes in client’s life since last session
o “Give me a brief picture of how the past week went”
• Check client’s mood and/or status of symptoms (formally &/or informally)
• Socialize client to provide concise responses
Feedback on Previous Session
• Check on client’s perceptions of prior session
o A “bridge” from previous session
• Give the client permission to be critical and to share negative feedback
• Handout: “Preparing for a Therapy Session”
• Rationale: Providing feedback on previous session motivates clients to prepare for each session by thinking about therapeutic content & process in between sessions
Agenda Setting
a. Collaborative decision re: what issues will be addressed in the session and in what order
b. Why set an agenda?
i. Time efficiency
ii. Limits digressions & keeps therapy “on track”
iii. Reduce “Hand on the doorknob bombshells”
c. Reasons for not adhering to the planned agenda
i. Client needs more time to discuss a particular issue
ii. A new topic arises which seems especially relevant
iii. Client’s mood changes for the worse in the session
iv. Shift from agenda is necessary for promoting rapport
v. Casual conversation is indicated to achieve a specific goal
d. Agenda should be a tool & not a constraint
e. Socialize client to agenda setting
Homework Review
a. Review underscores importance of homework & promotes compliance
b. Troubleshoot problems with homework
Discussion of Agenda
a. Devote majority of the session to discussion of agenda items
i. Discuss one item or divide time among a number of issues
b. Typically, ask client to prioritize agenda items and select an issue with which to start
c. Promotes an active, assertive, responsible role
d. At times, therapist suggests issue with which to start
i. Relates to session goal or target skill; likely to result in more progress
e. Therapist is encouraged to try to do the following with each topic:
i. Relate it to therapy goals
ii. Reinforce the cognitive model
iii. Teach the client a related skill
iv. Provide some symptom relief
v. Build & maintain rapport through empathy and validation
f. Using Naturally Arising Situations
i. Therapy work is generally accomplished through addressing and analyzing naturally arising situations and problems that the client brings to therapy
g. Cognitive model & skills are taught in the context of working on “day-to-day” problems
h. Therapist task is twofold:
i. Understand and address the particular situation
ii. Use that process as a context for teaching skills that could be applied to other problems
Devise & Assign Homework
a. Client and therapist work collaboratively to develop relevant HW assignments
b. Familiarizing client with the HW process
i. Early HW assignment may be to generate agenda items for next session
c. Provide rationale; relate HW to Tx goals
d. HW assignments should aim toward:
i. Teaching or reinforcing a skill
ii. Testing a thought, assumption, or belief
iii. Advancing client toward completion of a goal
iv. Reviewing key points or insights from therapy
Summary & Feedback
a. Throughout the session
i. Frequently summarize client’s content and present it in a clear and concise form
ii. Wrap up a discussion by summarizing what was covered and pointing out what will be discussed next
b. At the end of the session
i. Final summary includes major points covered
ii. Aim, where indicated, to extract the positive, emphasize progress, and promote upbeat, hopeful feelings in the client
iii. As therapy progresses, the therapist transfers responsibility for summarizing the session to the client
c. Elicit client’s reactions to the session and the therapist
i. Strengthens rapport
ii. Communicates concern for client’s perspective & responsiveness
iii. Creates opportunity to address process issues & resolve misunderstandings before they undermine therapy
Rationale for Measurement in CBT
a. Increased accuracy (validity?)
i. Contemporaneous measurement of mood/thoughts/behaviors more accurate than retrospective recall (e.g. memory loss may create biases affecting recall)
ii. Evaluating Progress & Outcomes (you may have people unwilling to recognize positive change/improvement/negative change, so subjective measures help with that)
iii. Baseline followed by repeated measures following the introduction of tx (showing it graph results may help change level of depression)
b. Maintaining focus on agreed upon goals (e.g. do we need to recalibrate and think about goals again)
c. Required by 3rd party payers
Selecting Progress/Outcome Measures: Desirable Qualities
a. Brief, user friendly, easily scored/interpreted, inexpensive, psychometrically sound (practical and pragmatic, computer scored or easily hand scorable)
