How does a therapist structure sessions? - Chapter 10

This chapter will discuss structuring sessions.

The therapist must plan the sessions around the issues and goals of the client and the therapeutic objectives. Sessions can be divided into three parts. Each part can be structured on its own.

What's the start of the session like?

The therapist can structure the first part of the session as follows:

• Do a mood check. The therapist will ask the client to compare how they are feeling now to how they did last week. The therapist compares the subjective description from clients (what they are telling the therapist) to the objective test scores (from a chart the client filled in before the session started). The mood check is not just about this day, but also about the time between the two sessions. A mood check is usually quick. As a therapist you should be careful that clients don’t attribute mood changes to external factors. The client should understand that their mood depends on their thinking patterns. Clients should feel that they have some control over how they feel. If clients state that nothing can improve their mood, it can be helpful write down ‘things that make me feel better’ and ‘things that make me feel worse’. This can give them insight in the fact that a more active lifestyle makes them feel less depressed. If clients are taking medication, the therapist should ask about any difficulties. As a psychologist you cannot change the medication, but you can help the client respond to eventual cognition that interfere with them taking medication.

• Set the agenda. This also is a very brief part of the session in which the therapist asks clients what they want to discuss in the current session. If clients engage in a lengthy description of the problem the therapist should interrupt and direct the topic back to setting the agenda. Lengthy descriptions of the problem are part of a later part of the session. The client can choose which topic on the agenda has priority. Sometimes the therapist can suggest the first agenda item himself if he thinks that a specific problem is the most important for now. The priority topics are the ones that are discussed first. If there is not enough time, less important issues can be moved to future sessions. It is important to note that you need not always adhere to the agenda. When deviating from the agenda, the change should be made explicit and the change can only take place with the client’s agreement. If the client drifts off to a topic that is not on the agenda, the therapist can interrupt the client and ask if he or she wants to deviate from the agenda.

• Obtain an update of the week. The therapist tries to get a general idea of how the client’s week went. This is a bridge between the previous session and the new one. The therapist should not only ask about problems, but should also emphasize positive experiences the client might have had. This will make the client realize that their week had some positive points and that they didn’t feel the same level of sadness the whole week.

• Review action plans. If a therapist doesn’t engage in this part, the client will eventually stop doing the action plan. Therefore it is an important part of the session. The previous action plan is discussed and new action plan is created for next week.

What's the middle of the session like?

The therapist can structure the middle part of the session as follows:

• Work on a specific problem and teach cognitive behavior therapy skills in that context. The therapist continues to reinforce the cognitive model and continues teaching about automatic thoughts. The therapist can provide some symptom relief through helping clients respond to their anxious thoughts.

• Follow-up discussion with relevant, collaboratively set action plans.

• Work on the next problem, till the time is up.

What's the end of the session like?

The therapist can structure the end part of the session as follows:

• Summarize session. The therapist can summarize the discussed content in the client’s words. If the therapist uses his/her own words it could seem to clients that the therapist didn’t understand them right. The therapist could also ask the client to summarize what they discussed and eventually add things the client forgot.

• Discuss new action plans.

• Elicit feedback. If clients didn’t fully express their reaction to the session, the therapist can ask them to complete a therapy report. If clients have negative feedback the therapist should positively reinforce them and try to solve the problem together with the client. Negative feedback is usually because the therapeutic alliance isn’t optimal.

As in the assessment and first therapy session it is still important that the therapist and the client have a good working relationship. If clients are starting to feel better, the therapist can begin to start working on relapse prevention.