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Staff Perspective: CBT for Depression – Elements of Session Structure

Staff Perspective: CBT for Depression – Elements of Session Structure

Marjorie Weinstock, Ph.D.

Over the past year I’ve taught multiple workshops on “CBT for Depression in the Military” to both uniformed and civilian providers, and one of the things I’ve noticed is that participants are often unfamiliar with the general structure of cognitive behavioral therapy (CBT) sessions.  One of the 10 basic principles of CBT is that “cognitive behavior therapy sessions are structured” (Beck, 2011).  Following a set session structure, regardless of the presenting problem, helps maximize efficient use of time during therapy, and it also helps make the therapy process clearer for patients.  I believe that this general session structure can be thought of as one of the hallmarks of CBT, so I wanted to briefly review the basic elements of a CBT session.

The components of a typical CBT session include:

  • A brief mood check
  • A bridge from the previous session
  • The setting of an agenda
  • A review of the previous session’s homework assignment
  • A discussion of agenda items
  • A homework assignment
  • A final summary

Periodic summaries also occur throughout the session.  These summaries communicate empathy and prompt collaboration between the therapist and the patient by ensuring that they both have a mutual understanding of what is being discussed.

A Brief Mood Check occurs at the beginning of each session and is an opportunity for the therapist to check on how the patient’s mood has been since the last session.  This process helps both therapists and patients keep track of patient progress over time.  Standardized self-report inventories, such as the PHQ-9 or GAD-7, are often used to assess a patient’s mood.

The Bridge from the Previous Session is a brief summary of the most important issues addressed during the previous session.  Its purpose is to help patients remember what was important in the previous session, and it helps ensure that the therapist and the patient are on the same page.

When Setting an Agenda, the therapist and patient collaboratively identify and prioritize a short list of topics to be discussed during that particular therapy session.  It’s important to be realistic about what can be accomplished (I recommend no more than 2-3 agenda items for a 45-50 minute session) and to keep treatment goals in mind when setting an agenda. While the process of setting an agenda at the beginning of a session may feel unfamiliar to novice CBT therapists, not setting an agenda can “deprive the patient of the opportunity to think through what is the most important to them to spend time on in session” (Beck, 2007).

A Review of Homework is a critical part of a CBT therapy session – if therapists don’t review assigned homework, they’re sending a message that homework isn’t important (which often leads patients to stop doing homework). It’s also important to remember to review the homework assignment with the patient in detail, not just acknowledge that it was completed.

The Discussion of Agenda Items is the really the principal activity that occurs in a CBT session (the “heart” of the session). Agenda items are generally discussed in the order that was developed while setting the agenda.  During this part of the session, therapists utilize cognitive and behavioral techniques to teach patients new skills. As noted above, Periodic Summaries generally occur throughout the session, frequently when the discussion of an agenda item has been completed. These brief summaries help provide a clear understanding of what’s been discussed. They can also be a useful time management tool, slowing down the pacing of the session and allowing time for reflection.

Assigning Homework is a primary component of CBT, as homework provides opportunities for patients to practice CBT skills in their everyday lives. In essence, homework is an opportunity for patients to consolidate learning. Homework assignments should be tailored to the individual patient and should grow out of the topics discussed during the session.

A Final Summary generally concludes the session. The goal of the final summary is to focus the patient’s attention on the most important aspects of the discussion. In addition, the therapist should ask for feedback about the session.

References:

Beck, J.S. (2007, March 8). Setting the agenda in session. [Blog post]. Retrieved from http://www.beckinstituteblog.org/2007/03/setting-the-agenda-in-session-j...
Beck, J.S. (2011). Cognitive behavior therapy: Basics and beyond (2nd ed.). NY: Guilford Press.
Wenzel, A., Brown, G.K., & Karlin, B.E. (2011). Cognitive behavioral therapy for depression in veterans and military servicemembers: Therapist manual. Washington, DC: U.S. Department of Veterans Affairs.

Marjorie Weinstock, Ph.D., is the Lead, Military Families & CBT for Depression at the Center for Deployment Psychology (CDP) at the Uniformed Services University of the Health Sciences in Bethesda, Maryland. She joined the CDP in 2009 as a deployment behavioral health psychologist at the Naval Medical Center San Diego. Prior to joining the CDP, Dr. Weinstock spent three years working for the Navy’s Fleet & Family Support Program, where she provided counseling services to military members and their families.

Staff Perspective: CBT for Depression – Elements of Session Structure | Center for Deployment Psychology

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