Cognitive Therapy (and other CBT approaches) are well-known for their focus on structure, goal-setting, agenda-setting, homework, practice, reviewing, etc. Indeed, Judith Beck, whose blog I have featured here a couple of times, outlines ten Principles of Cognitive Therapy, at least five of which (3, 4, 6, 7, 8) refer to these areas:
1. Cognitive therapy is based on an ever-evolving formulation of the client and their problems in cognitive terms.
2. Cognitive therapy requires a sound therapeutic alliance.
3. Cognitive therapy emphasises collaboration and active participation.
4. Cognitive therapy is goal oriented and problem focused.
5. Cognitive therapy initially emphasises the present.
6. Cognitive therapy is educative, aims to teach the client to be his or her own therapist, and emphasises relapse prevention.
7. Cognitive therapy aims to be time limited.
8. Cognitive therapy sessions are structured.
9. Cognitive therapy teaches clients to identify, evaluate and respond to their dysfunctional thoughts and beliefs.
10. Cognitive therapy uses a variety of techniques to change thinking, mood and behaviour.
She also provides a recommended structure for the initial session (post-assessment):
Update on presenting problem
Identifying immediate issues to work on, and setting goals
Educating client about the cognitive model
Eliciting expectations for therapy
Educating client re specific diagnosis
Providing a summary
(J. Beck, 1995)
Integrative CBT does believe in the importance of structure, and of processes like homework and feedback which help to provide some structure, but it is not necessary to be as organised as Judith Beck. It can be helpful in some cases to work at the highly-structured end of the continuum (e.g. with very chaotic clients, with children or adolescents, with groups in institutional settings, etc), but Integrative CBT also allows for a more non-directional approach, especially at Levels 1 and 5.
The key issue is continuity, building on gains made, internalising learning. We all know the situation where we have had a really good session with a client one week (lots of insights, changes, hope, etc) only to find that it has completely disappeared the following week, as if the previous session never happened (in fact, sometimes the client seems to have literally forgotten the previous session, even after promptings from the therapist). The idea of therapeutic structure, as I understand it, is to increase the chance of sustaining and building on therapeutic change and learning. Only to increase the chance, I’m afraid - there is no guaranteed way yet (I’m working on it…)
Reviewing progress, getting feedback from the client, revisiting and revising goals – all of these processes should be built into therapy in an ongoing way, not just done occasionally. Most important of all is the concept of “homework” (a word, incidentally, which I try to avoid using with clients, because of the negative, disempowering connotations it has for many people). If clients are to ultimately learn to be their own therapists (see point 6 above), they need to do most of their discovery, practice and experiential relearning out in the world outside the therapy room and in the time outside the therapy hour. In other words, the best collaboration is one where the client does most of the work.
Which brings us to another question: Does the therapy session need to last one hour (or the “50-minute hour”)? Integrative CBT is a pragmatic approach. Its aim is to give the professional help that the client actually needs, where possible - to be, as they say, “fit for purpose”. If a client reaches the stage where they will benefit more from attending for half an hour, in order to update, review and plan, then ideally the therapist should contract for half-hour sessions. Of course, this may not suit the therapist for practical reasons (e.g. scheduling, or the fact that the client is paying less), but that’s another issue. Similarly, there is no therapeutic need for every client to come every week – the crucial test, again, is whether continuity of progress is being achieved. If most of this progress is being achieved outside of therapy, all the better – this is, after all, the goal of therapy.
Beck, J. (1995) Cognitive Therapy: Basics and Beyond. New York: Guilford Press.