What problems may occur when structuring sessions? - Chapter 11

This chapter discusses problems that may occur when structuring sessions.

Problems can arise in structuring the session as a therapist. Some therapists fail to interrupt clients if they drift off of the agenda. This could be because the therapist has cognitions that interfere with interrupting a client. A therapist can also interrupt a client too much. The client could find this annoying. It is important to be open to each other and solve this problem. A second common difficulty in maintaining structure in the sessions can be that the therapist didn’t socialize the clients adequately into therapy. The therapist should explain the therapy structure to the client. Otherwise the client doesn’t know what is expected of him/her. A third common difficulty arises when clients have dysfunctional beliefs that interfere with their ability to commit to working in treatment. They may not have clear goals or may have unrealistic hopes about therapy. The therapist must help clients to respond to these kinds of interfering cognitions so that the therapy will work better. A fourth common difficulty involves clients that are unwilling to conform to the structure of the therapy. A reason for this might be that the therapeutic alliance needs strengthening.

What sort of problems can mood checks run into?

Common problems involve clients’ failure to fill out forms, annoyance with forms, or difficulty in subjectively expressing their general mood during the week. This could be because of faulty socialization and remembering clients about the rationale behind this may be sufficient to solve the problem. They might also be annoyed by the request of filling out all the forms, a therapist can then relate to the automatic thoughts that might accompany the reluctance of filling out the forms.

What difficulties may arise in setting the agenda?

Difficulties that most often arise in setting the agenda are:

• Rambling when contributing to the agenda. Sometimes clients are long-winded about a topic. It can help to gently interrupt and summarise.
• Sometimes clients fail to contribute to the agenda, because they do not know what to say or they are doing really well.

What sort of problems occur when asking for updates?

A common difficulty arises when clients provide too detailed an account of or unfocused rambling about their week. After several such sentences, the therapist should gently jump in and interrupt the client. A client can find this annoying, so the therapist should explain why he did it. If the client wants to continue to be too detailed, the therapist should explain to the client that in that why there won’t be enough time to discuss all the problems. If the client is fine with that, the therapist and the client should collaboratively look for a solution. For example: the therapist won’t interrupt for the next 5 minutes and then summarize what has been said. It is important to get clients into a problem-solving mode. Most clients are passive and feel hopeless about discussing their problems.

What sort of problems can a therapist run into when reviewing and assigning the action plan?

A typical problem arises when therapists, in their haste to get to clients’ agenda issues, fail to ask clients about the homework they did over the past week. This may lead to the client not doing their homework anymore or taking the wrong lessons from it. The opposite problem sometimes arises when the therapist reviews homework in too much detail before turning to the client’s agenda topics. This costs too much time and they won’t get to the real problems the client wants to solve.

What sort of problems occur when discussing agenda items?

Typical problems here include hopelessness, unfocused discussion, inefficient pacing, and the failure to make a therapeutic intervention. Unfocused discussion takes place when the therapist doesn’t interrupt the pclient when he/she drifts off the subject. Pacing is the overestimation of how many issues can be discussed in one therapy session. It is important to keep track of time and discuss with the client what to do if time is running out. It is optional for the client to also keep track of time. The therapist's failure to make a therapeutic intervention happens when the therapist fails to identify and respond to a client’s dysfunctional thoughts.

When should a therapist not follow the agenda?

An agenda is collaboratively set at the beginning of the session, but a therapist should deviate from this in the following situations:

• If you think the client is putting others or himself at risk. When this is the case, the therapist should address these problems.
• If clients can not focus on what you are discussing, because he is so distrissed by another problem. It may be wise to give this problem attention.
• The therapist should address a different problem or goal if an issue arises that is more pressing than the items on the agenda.

Why are final summaries and feedback so important?

The therapist needs to summarize a lot during the session to make sure he understands everything the client said. Problems arise when clients are distressed at the end of a session and you have not left sufficient time to resolve their distress, or when clients are upset but fail to relate their distress to you. A practical solution to avoid running out of time is to start closing down the session 5–10 minutes before the end.