Problems with setting the agenda
Agenda setting aims to structure the limited session time on making sense of whatever the client has found most difficult to deal with that week and teaching evidence-based techniques that address her thinking biases, errors and misinterpretations. Plain sailing, right?
I want to be sure, that by the end of the session, the client is satisfied that she ‘worked on’ whatever was terrible that week and that she has learned how to do it differently next time. It therefore follows that as therapist, I need to ensure that the skills that she learns in the session relate directly to those difficulties (and to her formulation) and that she knows how to practice these new skills in the coming week, so that she has the ability to respond differently if similar difficulties arise in the future. It’s therefore vital that I keep the formulation and maintaining factors firmly in the front of my mind when setting the agenda.
This approach makes the agenda setting truly collaborative: the client decides what we will focus on and I help to identify which problematic thoughts and behaviours are showing up and maintaining her distress. If we consistently set the agenda by looking out for the patterns and themes of thinking, feeling and behaving that keep her ‘stuck’ in her distress, the client learns not only the content of her patterns, but also the process by which she can reliably identify any and all patterns. She learns therefore that ‘I can myself use this reliable process to help me identify and redress my recurring patterns and themes of thoughts, feelings and behaviours that keep making me distressed.’ (Although she probably wouldn’t phrase it quite like that).
Of course, as all textbooks say, the agenda has several standing items every week:
• Update on the week’s moods or recent events.
• Reflection on progress to date.
• Discussing learning from the homework.
• Setting homework.
• Mutual feedback on the session.
The combination of this formulation-led approach and the standing agenda items helps answer some of the common problems that arise when agenda setting.
Firstly, there is the client who consistently does not add anything to the agenda from the week’s happenings or from her homework learning. Some of my clients, in later sessions, come to know that most of what they want to specifically discuss will emerge when we review their homework and they genuinely aren’t experiencing high levels of distress during the week. It is clearly ok not to be ‘adding to the agenda’ in this instance. However if the client routinely just doesn’t seem to have much to say proactively about what she wants to discuss, the less obvious possibilities are that she might:
• Be holding back because of shame/embarrassment/worry about her distress or problems.
• Not have actually done the homework – because she didn’t fully understand it or see its relevance to her.
• Be experiencing tension in the therapeutic relationship (Note that a subset of clients experiencing therapeutic strain may actually have a personality disorder and be replicating their inter-personal difficulties within the therapeutic relationship).
• Be considering terminating therapy prematurely.
• Not be suited to CBT at this time.
• Be ‘cured’ – but that would probably be obvious!
Each of the above possibilities will need to be explored sensitively, using the usual methods of empathic questioning and Socratic dialogue.
A common second problem when agenda setting is when the client brings too much to the agenda. In this case, I whiteboard a long-list of potential patterns/themes and maintaining factors and then ask the client to prioritise which one or two she would like to focus on in this session. It is definitely better to do a small number of topics thoroughly than skate over more topics superficially.
Another problem is getting side-tracked off the agenda. If this occurs, I mention it aloud as soon as possible and ask the client
‘Is it ok with you that we are moving onto a topic that we hadn’t actually put on the agenda? Do you think we should continue with this? What will we drop off our agenda instead for this week then?’
Personally I don’t tend to allocate time to each agenda item, although I know that the CTS-R suggests this. It seems a bit artificial to me, although sometimes I do try it with particularly chatty clients, with an educative rather than a punitive intent in mind.
Having said all this, I freely admit to tending to run over time rather than under time! As a pragmatist and given that I have a little freedom in private practice, I try not to schedule a patient on the hour, every hour. Building in a little catch up time is a practical way to compensate for over-running and for looking after myself. That is also another important part of my agenda…
Summary points
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Keep the formulation and maintaining factors firmly centre-stage when setting the agenda.
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Consider the common reasons why the client may consistently not add topics to the agenda.
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If the client adds too much to the agenda, collaboratively prioritise which topics to address this session.
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If you get side-tracked off the agenda, acknowledge this and ask the client whether to re-track or deliberately diverge from the agenda.