Setting an effective agenda

This is the Cognitive Therapy Scale (CTS-R) competency that I have struggled with the most as a trainee. The problem has mainly been around setting it with genuine collaboration. This is because I have been too nervous that the patient will lead it towards something I haven’t prepared for/don’t know much about/can’t remember the intervention for. If this sounds familiar to you, then read on…

 The basic skeleton for any effective communication about any important issue (in life in general actually!) is:
• This is what we are going to talk about - planning content
• This is us talking about it - delivering content
• This is us recapping what we’ve just talked about - reinforcing content and planning next steps

In each CBT session (bar the first two sessions which are for assessment and formulation) this translates roughly to:
• What happened this week that you want to focus on in this session? (i.e. stressful events and learning from homework) i.e. planning content
• How does what you want to focus on relate to your maintaining processes, formulation and goals, such that we can select CBT skills to learn in this session? i.e. delivering content
• How will you translate these new skills into effective practice for this coming week? i.e. reinforcing content and planning next steps

Once again, I cannot emphasise enough how revolutionary the concept of maintaining processes has become to how I ‘do CBT’, including how I set the agenda. Looking out for patterns and themes of thinking, feeling and behaving that keep the client ‘stuck’ in their distress – these are key to setting the agenda for every session.

By following this principle, I roll out whatever CBT condition-specific model and protocol that I’m following, as it applies to whatever has most distressed the client that week, rather than in the steps that the textbook describes it in. Of course, this takes a certain amount of familiarity with the model and protocol – I didn’t and couldn’t do this when I was a complete novice, but after about 70 to 100 hours of client sessions, I think most trainees can have a stab at this approach.

Setting the agenda around working with maintaining processes means, in practice, that I proceed as follows:

I begin: 'How was your mood in general this week? On a scale of 0 to 10, where 10 is the most severe anxiety or depression and 0 is none at all?'

Next: 'What learning did you take away from our last session? How did you put it into practice this week?' These questions reinforce the CBT model of active learning and putting new skills into practice between sessions. It also adds reviewing the homework to the agenda as a standing agenda item

Then: 'What would you like to focus your attention on this week?' I let the client speak for a couple of minutes, to outline her week/hear what is on her mind/make her feel heard/help me to see where the session might be heading

As the client outlines the issue/situation that troubled her during the week, I am internally noting and micro-formulating how the processes of thinking, feeling and behaving that are maintaining her problems are being played out in this scenario.

We add each issue/situation to the agenda long-list. If the client offers up several issues/situations for discussion, I note if there is a common pattern or theme linking the topics e.g. the common trigger is ‘feeling criticized’, or ‘ruminating’ or ‘procrastinating’

I then test this hypothesis with the patient: 'If I’ve understood correctly, it sounds as though there might be a common theme here about…' I’m trying here to ‘name’ the processes that are making these situations still problematic, without eliciting every detail of the entire situation. It also gives the client a chance to correct my hypothesis, or phrase it in a way that resonates more with her

We may by now have a list of three to five maintaining processes on the agenda. 'Which of these would you like to work on first? And after that, which one should we look at next?'

It is probable that some of these maintaining processes will also have been addressed during the homework tasks, so we can incorporate debriefing the homework into the agenda in this way. Occasionally reviewing homework becomes a separate agenda item in itself.

I document all the agenda items on a sheet of A4, with both of us looking at it together during the prioritising process.

The whole process usually takes eight to 10 minutes. This is time well spent as defining the maintaining processes (planning content) leads logically to teaching the patient specific CBT skills (delivering content).

The penultimate agenda item is usually planning the next homework task.

The final agenda item is asking for feedback: 'Can you give me some feedback in a nutshell about this session –what you learned, what went well in this session or if anything didn’t work well for you?' These last two steps constitute the last stage of reinforcing content and planning next steps

While setting the agenda and reviewing homework are presented as quite distinct CTS-R competencies and steps, in practice, I find that they are often inter-twined.

Summary points

  1. The agenda routinely follows the principle of planning content, delivering content and reinforcing content and planning next steps through homework tasks
  2. Set the agenda by referring continually to the formulation, particularly the maintaining processes
  3. Listen out for cognitions, patterns and themes in how the patient describes what they want to focus on this week – this guides what to focus on in the session, rather than a mechanical adherence to the ordered steps in the relevant protocol
  4. Create a long-list agenda, then prioritise items to be discussed this session – one or two topics usually take up the time available
  5. The final agenda item is setting homework to consolidate the new learning and test it in practice
  6. The final step is to ask for feedback on the session

 

Reference: Manual of the Revised Cognitive Therapy Scale, James, I.A., Blackburn I.-M., & Reichelt F.K. Dec 2001