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Structuring a CBT Session

I have been training therapists on CBT for anxiety and OCD for many years and one of the first things we discuss is session structure.  I am also training an intern right now and have become acutely aware of everything I do in a session so that I am modeling skills that are helpful to him. I find that clients really appreciate knowing what to expect from a road map of what their treatment plan looks like to how long treatment will take.  Having a structured session and explaining to them what they can expect even from a session, allows them to make use of their time wisely and prepare for each session.

At the beginning of the first session , I socialize clients to the structure of our sessions.  I tell them that each session will begin with checking in with their mood and how things have gone in between our sessions. Then I will ask them what they want to address in our session. I ask them to give this to me in the form of a title so I can jot it down in my notes. I let them know that I will keep track of time and I will make sure that I leave enough time to address these items. If they have several items, I ask which are the most important to discuss first, in case we run out of time. I let them know that I will write down the others to discuss at our next session.

Once we have checked in and set an agenda, we discuss their homework from the previous session. I do this immediately, so they understand that practicing their skills outside of our sessions is one of the most important parts of their therapy.  I let them know that success is in the practicing, not in getting it perfect, as many of my anxious clients want to do their homework perfectly or want to please me and can often lose site of the purpose of homework. We often spend 20-30 minutes just discussing the homework  they practiced as it provides a lot of information on their vulnerabilities, their automatic thoughts and beliefs, as well obstacles to facing their fears.

The next thing in our session is to teach and practice together a new skill. This could be anything from how to challenge automatic thoughts to experiencing an exposure or teaching social skills. It can be tempting to teach a skill and give it as homework to practice without actually practicing it in session. However, I believe this is a mistake therapists make with their clients. Practicing in vivo exposures , role playing how they will talk back to OCD, or trying out a behavioral experiment can give you crucial information to identify ways they may struggle with their homework.  I find the more a client practices in session, the more likely they are to practice outside of our session.

After practicing skills, we develop their homework for the next session. Although we function as a team in treatment, I believe it is important for a client to decide on their homework assignment. They need to have a stake in this by deciding what they will do to practice their new skills outside of session.  We also discuss how frequently they need to practice and remind them that home work his to learn more about their disorder, change their relationship with fear, accept uncertainty, and develop anxiety tolerance.

The end of the session is left to summarize the session and to provide feedback. Again, you can guide the client to these questions, but they have to answer them.  Not only does it help both of you highlight the important parts of the session to remember going forward, but it provides you feedback to create a session that is more in tune with your client.

For more information about CBT session structure you can read Cognitive Behavior Therapy: Basics and Beyond by Judith Beck.

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