+ Chapter 4
CBT Session Structure: Purposeful and Flexible
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CBT Session Structure
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CBT Session Structure
CBT skills addressed in the proceeding chapters will have little
to no value if the directionality and focus that are afforded in
structured sessions are lacking
Most clients want and need structure
Clients attend therapy because they are distressed and some may
still be unsure if therapy is a viable option
Many clients feel vulnerable at the onset of therapy
Structure from the first session instills comfort and hope that therapy might
provide some relief to their distress
It also demonstrates your expertness, trustworthiness, and
attractiveness as a therapist – important factors for developing
a therapeutic alliance
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CBT Session Structure
Consistent session structure socializes clients to CBT
Allows you to model the collaborative nature of CBT
Provides direction for both you and the client
Even experienced therapists require guidance in maneuvering each
session
Enhances therapeutic efficiency by facilitating organized
therapy that stays focused on the problems of most relevance
and corresponding goals and interventions
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CBT Session Structure
How much structure is necessary for your clients will vary,
often depending on the current phase of therapy
Early phase therapy will require significantly more structure and
guidance by the therapist compared to late phase therapy
Each session is broken down into four stages: pre-session,
early session, middle session, and late session
Table 4.1 – Therapy Session Stages
Highlights each stage and its associated components
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Pre-Session Stage
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Pre-Session Stage
This stage is probably the most critical because how you
prepare before you session will influence the effectiveness of
the following three stages
Preparing for the next session typically takes only 5 to 10
minutes
Yet, can often be overlooked by therapists
Consists of two key components:
Review client information
Pre-session formal assessment
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Pre-Session Stage
Sample Form 4.1 – Therapy Session Worksheet
Helps make sure you review and prep for both content and process
during the pre-session stage
Relevant information that is typically gathered at each session
stage is addressed in its corresponding section
Some therapists do not like or do not think it is necessary to take
notes during sessions
Research shows that therapists’ perception of what they remember
from a recent session is often inaccurate
Effective CBT often requires clients taking notes as well
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Review Client Information
Improves overall therapy efficiency and effectiveness by way
of having a purposeful direction for each session
Recalling basic information about clients (e.g., recent weekend
vacation, favorite hobby, or grade on recent exam) can help
build a strong therapeutic alliance
Sources of information include recent progress notes, Therapy
Session Worksheet, and Client Therapy Notes Worksheet
(Sample Form 4.2 – discussed later)
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Review Client Information
Review client’s case formulation and treatment plan, including
goals and interventions
Can supplement with “process objectives”
An intervention is a statement of what will be done to work
toward a goal (e.g., cognitive restructuring)
A process objective states how it will actually be done (e.g.,
complete thought record with focus on dichotomous thinking)
Although setting the agenda involves collaboration with your
client, you should still note in advance what you believe
should be covered in session
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Pre-Session Formal Assessment
Self-report assessments (5-10 minutes) right before session
begins
Can provide immediate feedback and compare to previous
assessment scores
If possible, ask clients to arrive about 10 to 15 early
If this is not possible, on occasion it is okay to have assessments
completed during the first 5 minutes of the session
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Early Session Stage
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Early Session Stage
There are many “small” parts to cover in this stage, but they
will shape and influence the direction of your agenda items by
the middle stage
Check-in
Mood and symptom check
Set agenda
Review homework
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Check-In
Personalize greeting
Show sincere interest in your clients and possibly remember any
recent relevant events between sessions
e.g., “How was your weekend vacation?” “Did you get a chance
to visit your mother over the past week?”
Try to elicit positive experience – hope/optimism
“You stated last week you were looking forward to your
daughter’s birthday party. How did it go?”
Sometimes information revealed during the check-in may be
relevant enough to inform and possibly modify your agenda
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Mood and Symptom Check
Assess current mood and emotions over the past week (or
since last session)
Builds rapport while naturally monitoring treatment progress
Eliciting “fresh” emotions to recent events is most useful
“Here and now” effect – incorporate any themes into your agenda
If appropriate, you can do more formal symptom checks
e.g., ask clients to rate their depression or anxiety on a 0-10
scale
e.g., number of binges, substance use (frequency and amount)
Can also review any monitoring forms for homework
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Mood and Symptom Check
Review any pre-session (or prior session) assessments
Provides insight into therapy progress (i.e., effectiveness)
Focus on individual items
Consider specific areas of concern or possible contradictions
e.g., “You said to me during our check-in that you haven’t had any thoughts
of suicide over the past week, but I’ve noticed that you selected ‘sometimes’
for thoughts of suicide on the suicide scale.”
Follow-upon any medications including side effects,
adherence, and any related problems or questions
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Set Agenda
Iftreatment planning sets the stage for the course of therapy,
then agenda setting sets the stage for the course of each
session
Driving force for the direction of therapy
Most effective when connected to treatment goals (specific and
measurable)
Make sure interventions allow for the opportunity for clients to
experience some level of progress and success
By the first or second session (part of psychoeducation),
explain the purpose, process, and value that comes with
agenda setting
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Set Agenda
Always collaborate with clients; increasing flexibility with
each phase of therapy
i.e., client has more of a role in developing the session agenda as
therapy progresses
Balance transition from teacher—student relationship to mentor-
protégé relationship
May need to prioritize agenda items based on session time,
clients’ immediate needs, and level of distress (need to
“triage”)
Itis okay to modify an agenda item in session if it is not
addressing a key problem effectively
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Set Agenda
Sample Form 4.2 – Client Therapy Notes Worksheet
Helps clients monitor their thoughts/emotions, reflect on
homework, focus on their identified problems and positive
experiences, note progress on learning new skills, and reflect on
experiences during session and outside of session
Asking clients to share their notes can be a helpful contribution to
the session agenda
Enhances clients’ preparedness to both collaborate and take
responsibility for their therapeutic progress
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Review Homework
Homework must be reviewed every session
Can be part of a check-in or more detailed
Not reviewing homework will result in clients not completing
it and damage the therapeutic alliance
*CBT without homework can negatively impact client outcomes
Reviewinghomework is a great way to bridge content and
themes from the previous session
Ideal to practice newly learned CBT skills between sessions
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Early Session Stage
Video Vignette 4.1 (p. 85)
MDD-6: Early Session Stage—Early Phase Therapy
Video Vignette 4.2 (p. 86)
MDD-13: Early Session Stage—Middle Phase Therapy
Video Vignette 4.3 (p. 88)
MDD-13: Early Session Stage—Late Phase Therapy
Discussion Questions 4.1 (p. 89)
Activity 4.1: Early Session Stage (p. 89)
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Middle Session Stage
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Middle Session Stage
Number of agenda items and how much of a lead you or your
clients take in initiating and moving forward with the agenda
will depend on the phase of therapy and the type of problem
The content and process can vary greatly for each client
depending on presenting problems, goals, and corresponding
interventions
The following sections serve only as a general template:
Review problem
Problem-solving strategies
Feedback and summarize
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Review Problem
Best to use problem/event that is recent
Strong emotional content and easier to recall
Better chance for immediacy and engagement
Conceptualize how problem fits in case formulation/cognitive
model
Most problems are an extension of or a part of their distress, either
as a contributing factor or as outcome
“Micro” problem tied into specific “macro” goals and
interventions
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Problem-Solving Strategies
Collaboratively decide on how you will focus on the problem
using the cognitive-behavioral model:
Psychoeducation of specific CBT skills
Basic problem-solving strategies
Behavioral activation
Emotion and thought identification
Modification of automatic thoughts and core beliefs
Relaxation techniques
Exposure
The focus here is to provide a guide in determining possible
intervention options to resolve the problems
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Feedback and Summarize
Provide periodic feedback of encouragement and redirection
Encourage and elicit feedback from clients about what is and
is not working for them
Clients can report their current symptom distress (e.g., 0-10)
Client
feedback and self-report of distress will allow you to
more accurately assess the effectiveness of your interventions
and possibly make any necessary modifications
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Feedback and Summarize
Summarize by highlighting the rationale for the approach,
what skill was learned/used, how it can be applied to other
problems, its relation to a particular treatment goal, what was
helpful and not helpful, and the next steps in moving forward
Depending on phase of therapy, either you or your client can
provide the summary
This is a good opportunity to assess their understanding of the
problem and how the interventions were helpful, including their
current level of distress
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Late Session Stage
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Late Session Stage
Typically the last 5-10 minutes of session
Justas essential as the other stages because it provides an
opportunity to integrate key conceptual themes and review
what was learning during the session
Can be your bridge for next session
Often done through assigning homework
Consists of the following components:
Summarize session
Assign homework for next session
Final questions and feedback
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Summarize Session
Focus on the overall themes that were covered in session
Explicitlyintegrate the cognitive-behavioral model relevant to
the interventions implemented
Demonstrates to your client that the work done during the session
was purposeful toward overall symptom distress reduction and
improved quality of life
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Summarize Session
With more therapy experience, clients can summarize session
Can be a great opportunity to integrate and modify their own
conceptualization of distress
Highlight any symptom relief
Connecting what clients have done in session to how they
currently think and feel can be very powerful for developing and
enhancing hope and motivation to change
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Assign Homework for Next Session
Canassign next homework assignment either before or after
summary
Should be based on current session content while also keeping
in mind your focus for next session
Provide a clear rationale for the homework assignment and
convey the role it will have during your next session
The more clients understand this, the greater the chance they will
complete the assignment with effort
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Final Questions and Feedback
Ask clients to review their Client Therapy Notes Worksheet
Elicit questions or feedback about any part of the session
Remind clients to take any final notes to review before next
session
Check-in on their overall experience of therapy
What is working?
What can be done to improve therapeutic experience?
Remember to take down any final notes on your Therapy
Session Worksheet
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Late Session Stage
Video Vignette 4.4 (p. 93)
PDA-5: Late Session Stage—Early Phase Therapy
Video Vignette 4.5 (p. 97)
PDA-8: Late Session Stage—Middle Phase Therapy
Video Vignette 4.6 (p. 99)
PDA-10: Late Session Stage—Late Phase Therapy
Discussion Questions 4.2 (p. 101)
Activity 4.2: Late Session Stage (p. 101)
+ Common Challenges for CBT
Session Structure
