Here are some tips taken from the CBT bible, Back to Basics, by Beck to help therapists carry out their work in the most effective way.
Clients can be fearful of what to expect from treatment so it will help to set an agenda at the start of each session. This also allows you to curtail any tangential and less relevant diversions once the session has started. It will also help them to adjust to the structure of each session and to reach the end of the session at an appropriate point. In doing is it is important to also ask them what they’d like to address in session (problems, worries, concerns, what came up in the week?) so that they get an opportunity to discuss these issues.
If a client starts to talk for too long, interrupt them gently but check they’re OK with it. If they continually do this then make sure that you are making an effort to:
- socialise them to the agenda
- ask them for a brief summary
- ask them to write down agenda points for the session as part of homework
- compromise by offering them 10 mins or a limited period where they can offload first then summarise
- ask them to choose which issue to focus on
Summarise are essential and need to include:
- You summarising what they’ve said
- Them summarising what the key learnings are and reasons for doing things
- You summarising each section of each session
Homework is important because it brings lots of opportunity for learning and embedding learnings into the client’s memory; it also is essential if the client is to work independently. However often, clients struggle to complete it. They are more likely to do it if:
- The client has the rationale for why it’s helpful
- Homework is reviewed each session
- You talk through how to do it in session, or start it in session
- You ask about obstacles that will get in the way and problem solve that
- Get patient to write down homework
- It is chosen in a collaborative way
- You address negative thoughts about homework
Homework can be:
- Behavioural Activation
- Thought record
- Challenge thoughts
- Problem solving
- Relaxation / assertiveness / time management
- Behavioural Experiments
- Prep for next session / do standard questionnaires
- Using their summary or revised though or mantra cards
Other helpful approaches to homework can be:
- Get them to put frequency and deadlines on it
- Get them to do a decisional matrix of pros and cons of what will happen if they don’t do it
- If they can’t do it, ask them to note down the thoughts that were getting in the way
- Pair the activity with their routine, i.e. do it straight after lunch
- Get person, diary, post its or phone to remind them to do it
- Ask them to call the office and let you know when they’ve done it
Ask them how likely they are to do it and get them to envisage doing it. Ask them when and how they will do it, and what thoughts, feelings and behaviours will happen, and ask for what barriers may get in the way.
If they are unlikely to do it because of negative thoughts then role play it, with you arguing for doing it (the intellectual side of it) and them arguing against doing it (the emotional side of it) and then reverse
roles. If they make negative predictions and this stops them doing homework, then set them up to do a Behavioural Experiment, to see if it happens.
For Behavioural Experiments, get them to predict their feared outcome but also get them to figure out other reasons for that outcome if it did arise, just in case it does arise. Get them to write that down.
If their reason for not doing homework is:
Time: Problem solve this but also give the example of if they needed a blood transfusion they would find a way to do it. Explain that the homework situation is not life threatening but it shows that finding time is possible. Explain that it’s only during these sessions, not forever and also that it won’t take that long.
Energy: ask them how long they think homework will take. Challenge any unrealistic expectations and explain that you don’t need much energy to do it. Ask them to test their prediction of them being exhausted afterwards and report back to you.
Perfectionism: Explain that CBT and the homework is a skill to be learnt, and that no one can do it rig first time and that the getting it wrong is part of the learning process. You could even ask them to do it deliberately wrong
the first time to get them used to not striving for perfection but for growth.
Clients may struggle to adjust to the end of treatment. To help them adjust, talk about it from the start
and manage their expectations that this support will not be forever, explaining that the aim is to get them to be their own therapist.
Put an emphasis on their effort and progress
throughout so they have a sense of self-efficacy before you talk about endings. Help them reframe their negative thoughts about endings
List the tools they’ve learnt with them:
- Breaking problems down into chunks
- Brainstorming solutions
- Testing thoughts
- Thought records
- Scheduling activities
- Distraction and refocusing
- Hierarchies of avoided tasks to build confidence
- Credit lists
- Decisional matrix
Help them envisage realistic setbacks
and formulate a plan of action for when they occur.
Schedule booster sessions if needed but get them to prepare by writing down how they’re using coping strategies along the way.
Problems occur in:
- Structure and pace
- Dealing with nats
- Accomplishing goals
- Processing of content
- External environment
Fix them by doing this:
- Complete a more thorough diagnostic evaluation
- Double check your formulation and discuss is with your client
- Read up on their issues
- Ask them for feedback on their experience working with you
- Go over their goals for therapy
- Consider your own negative though
- Review the CBT model and discuss issues about understanding and applying this with the client
- Check their understanding of the treatment plan and if they’re happy with it
- Check the client’s understand of their responsibilities
- Work on the key thoughts, feelings and behaviours in each session
- Change pace, intensity, level of empathy, amount if coaching vs didactic approach, difficulty of session structure and homework
- Refer for neuropsychological testing if something organic may be at play
www.happii.uk is a website providing information about mental health and wellbeing. Happii.uk is provided by Anna Batho, a therapist working in High Wycombe and providing therapy in Amersham and the wider Buckinghamshire (Bucks) region.You can contact her here.