4. 结构化你的会话

第四章

结构化你的治疗会话

你有机会尝试为新客户来访或现有客户来访设定目标吗？你是否尝试了前几章的其他家庭作业？当你想到你尝试过的干预措施时，你希望继续做哪些？

如果你没有机会尝试设定目标，请花点时间识别是什么障碍阻碍了你。选择一个你认为愿意设定目标的特定客户来访，安排在接下来的一周内见面。现在想象自己在办公室与这位客户来访设定目标，然后试着去做！

设定议程

我们已经确定了客户来访的问题，了解了历史，解释了认知行为疗法（CBT）模型，并设定了目标。这通常需要一到两次会话。你现在准备好开始解决客户来访的问题了。在本章中，我将重点介绍如何结构化或组织你的治疗会话。

议程项目 #1：组织你的治疗会话

议程项目 #2：进行检查

议程项目 #3：合作设定议程

议程项目 #4：执行议程

议程项目 #5：为下一次会话开发有用的作业

议程项目 #6：回顾会话并征求反馈

执行议程

研究表明，结构化治疗，特别是设定议程、遵循议程和布置作业是有效治疗的关键因素（Shaw et al., 1999）。我的许多学生告诉我，结构化会话是他们学到的最有用的认知行为疗法技能之一；我相信你也会发现它很有帮助。

议程项目 #1：组织你的治疗会话

结构化的会话意味着治疗会话有一定的顺序和组织。以下是五个基本组成部分的简要概述。我将在本章后面详细讲解每个部分。

检查：这是一个快速更新，包括自上次会话以来发生的情况，以及与上次会话的衔接。
设定议程：你和客户来访共同决定在当前会话中重点关注哪些问题。上一次会话的家庭作业可以在检查过程中或作为议程设定的一部分进行回顾。
执行议程：这涉及解决议程上确定的问题。
家庭作业：你和客户来访合作为下一次会话开发家庭作业。
回顾：在会话结束时，简要回顾当前会话的内容，并征求客户来访的反馈。

一开始，一个会话中涵盖所有这些组成部分可能会显得很多。然而，一旦你习惯了使用结构化方法，它就会变得自然流畅；我预测你会想知道你是如何用其他方式工作的。学习使用结构化方法类似于学习开车。当我第一次学开车时，我被需要同时做的很多事情压得喘不过气来。我还记得第一次把父母的车停进车库的情景。我当时如此专注于不要踩太多油门，记住刹车在哪里，确保不撞到右边的东西，结果却把车的左侧在车库墙上刮了一道痕。我当时甚至没有及时踩刹车的反射动作。随着练习，开车变得简单了；你可能会高兴地知道，我已经多年没有撞墙了！就像开车现在对我来说是一种常规活动一样，一旦你与几位客户来访练习过，使用结构化方法也会成为你的正常工作方式。

你对结构化会话的态度

有些治疗师立刻喜欢上了结构化会话的想法；另一些则有负面反应，如“结构太死板了”、“我的客户来访不喜欢”、“它会打断治疗的流畅性”。然而，我相信在你尝试与几位客户来访进行结构化会话后，你会开始觉得“结构让我的治疗更有焦点”、“我的客户来访会喜欢有机会告诉我他们想关注什么”。花点时间注意你自己对使用结构化的想法。

进一步的知识点阐述

结构化会话的重要性：
- 结构化：结构化会话意味着治疗会话有一定的顺序和组织。这有助于治疗师和客户来访保持焦点，确保会话高效有序。
- 关键组成部分：结构化会话包括检查、设定议程、执行议程、布置家庭作业和回顾会话。这些组成部分确保会话有条不紊地进行。
设定议程：
- 检查：快速更新客户来访自上次会话以来的情况，确保与上次会话的衔接。
- 设定议程：与客户来访共同决定当前会话的重点问题。上一次会话的家庭作业可以在检查过程中或作为议程设定的一部分进行回顾。
- 执行议程：解决议程上确定的问题，确保会话内容集中且有效。
- 家庭作业：与客户来访合作为下一次会话开发家庭作业，确保客户来访在会话之间继续进步。
- 回顾：在会话结束时，简要回顾当前会话的内容，并征求客户来访的反馈，以便不断改进治疗效果。
实践建议：
- 逐步实施：一开始可能会觉得结构化会话包含的内容很多，但随着实践，你会逐渐适应并觉得自然。
- 客户来访反馈：征求客户来访的反馈，了解他们对结构化会话的看法，根据反馈进行调整，确保会话对客户来访有益。

通过这些练习和反思，治疗师可以更好地组织和管理治疗会话，提高治疗的效果。结构化会话不仅帮助治疗师和客户来访保持焦点，还能提供一种衡量进展的标准，使治疗更加有效和有针对性。

向客户来访解释治疗会话的结构

向客户来访解释治疗会话的结构将帮助他们感到更加舒适，因为他们会知道期待什么。我认为治疗类似于访问一个外国国家。如果你不了解当地的习俗，不知道会发生什么，你会感到不舒服。我在二十多岁时曾在印度尼西亚度过一年。我还记得第一次参加印尼婚礼的情景。我走进房间，环顾四周，完全不知道该做什么。毫不夸张地说，我感到非常尴尬。直到邀请我的朋友牵着我的手，温柔地让我坐下，并解释了将要发生的事情和我需要做什么，我才松了一口气。解释治疗的结构类似于解释外国的习俗。如果客户来访知道期待什么，他们会更加放松和信任。你可以在 http://www.newharbinger.com/38501 找到一份《解释治疗会话结构》的手册。

向新客户来访解释治疗会话的结构

这里是一个例子，说明你可以如何向新客户来访解释会话的结构。我不仅解释了我将要做什么，还解释了为什么这样做。

治疗师：我们已经花了一些时间了解你的问题并设定了治疗目标。我想解释一下我希望如何结构化实际的治疗会话。每次你来的时候，我希望能够从一个简短的检查开始，这样你可以告诉我自从我们上次会面以来发生了什么，以及你最近的情况如何。然后，我会列出你在这次治疗会话中想要讨论的内容。我发现这样做可以使我们的会话更加聚焦，这样我可以确保我们讨论对你最重要的事情。我称之为设定议程。通常，你和我会在会话之间决定一些家庭作业。如果有家庭作业，我会检查进展情况。在会话结束时，我们会花一些时间总结我们讨论的内容，确保我们在正确的轨道上。我们还会看看是否有适合你在下次会话前尝试的家庭作业。你觉得这样怎么样？

客户来访：好的。

治疗师：那我们就开始吧。你能告诉我这一周的情况如何，然后我们可以看看今天你想要关注什么吗？

对于新客户来访来说，这是一个直接的过程，几乎总是顺利进行。

向现有客户来访解释治疗会话的结构

如果你还没有使用结构化的格式，你可能会觉得向现有客户来访介绍结构化会话有些尴尬。这里是一个例子，说明你可以如何开始。

治疗师：我一直都在思考我们的会话，今天我想尝试一些新的东西。我们先从一个简短的检查开始，这样你可以告诉我自从我们上次会面以来发生了什么，以及你最近的情况如何。然后，我会列出你今天在这次治疗会话中想要关注的问题，并决定我们从哪个问题开始。我认为这将有助于聚焦我们的会话，这样我可以确保我们讨论对你最重要的事情。在会话结束时，我们会花一些时间总结我们讨论的内容，并看看你是否喜欢这种方式。你觉得这样怎么样？

请注意，我对我们将要做的事情非常明确，并且会检查客户来访是否喜欢这种新的工作方式。我猜测，几乎所有客户来访都会觉得有结构化的会话是有帮助的。一旦解释了设定结构，它就会成为治疗的正常部分。习惯于结构化的客户来访通常会在会话前花时间思考他们想要讨论的内容。治疗变得更加聚焦；客户来访通常会带着一两个议程项目来。当客户来访习惯于结构化格式时，我通常会从以下几句话开始：

治疗师：你好，见到你真好。我想检查一下你最近的情况如何，看看你今天想要关注什么，以及你的家庭作业进展如何。

进一步的知识点阐述

解释治疗会话结构的重要性：
- 增强舒适感：向客户来访解释治疗会话的结构可以帮助他们感到更加舒适，因为他们会知道期待什么。
- 类比说明：将治疗比作访问一个外国国家，强调了解当地习俗的重要性，帮助客户来访理解为什么需要结构化。
结构化会话的关键组成部分：
- 检查：简短更新客户来访自上次会话以来的情况，确保与上次会话的衔接。
- 设定议程：与客户来访共同决定当前会话的重点问题，确保会话内容集中且有效。
- 执行议程：解决议程上确定的问题，确保会话内容集中且有效。
- 家庭作业：与客户来访合作为下一次会话开发家庭作业，确保客户来访在会话之间继续进步。
- 回顾：在会话结束时，简要回顾当前会话的内容，并征求客户来访的反馈，以便不断改进治疗效果。
实践建议：
- 新客户来访：向新客户来访解释会话结构时，明确说明每一步的目的，确保客户来访理解并接受。
- 现有客户来访：如果现有客户来访不习惯结构化会话，可以逐步引入，解释其好处，并征求客户来访的反馈。

轮到你了！

在想象中练习：解释会话的结构

我希望你能够想象向新客户来访和现有客户来访解释会话的结构。在开始这项练习之前，请从1到10评估你在向新客户来访和现有客户来访解释会话结构时的舒适度，其中1表示非常舒适，10表示非常不舒适。在练习结束后，再次评估你的舒适度，看看是否有变化。

现在，让我们开始练习。

与新客户来访练习

想象自己在办公室与一位新客户来访。花一点时间环顾四周，注意房间里的声音和气味。现在想象你想要解释你希望如何结构化会话。阅读下面的内容，同时想象自己在说这些话。你也可以使用自己的语言。真正地听和感受自己在解释如何结构化治疗会话。然后，想象自己再向同一位客户来访解释两次会话结构。每次想象客户来访都给予积极的回应。

客户来访：好的。

治疗师：那我们就开始吧。你能告诉我这一周的情况如何，然后我们可以看看今天你想要关注什么吗？

与现有客户来访练习

选择一位你认为会从结构化方法中受益并且喜欢这种方法的现有客户来访。尽量在脑海中形成他的形象。现在，想象自己在办公室。阅读下面的内容，同时想象自己在说这些话。你也可以使用自己的语言。然后，想象自己再向同一位客户来访解释两次会话结构。每次想象客户来访都给予积极的回应。

客户来访：好的。

治疗师：那我们就开始吧。你能告诉我这一周的情况如何，然后我们可以看看今天你想要关注什么吗？

议程项目 #2：从检查开始

检查是一个机会，让你大致了解客户来访的情况，了解她的生活中是否有任何新的发展，并检查上一次会话中提到的任何问题。这样，如果客户来访的生活中有任何重大事件或变化，你从会话一开始就了解这些情况。

下面是大多数会话中检查的主要组成部分。根据会话的流程，你不一定按以下顺序完成这些组成部分。

检查客户来访生活中是否有任何新的发展，以及自上次会话以来客户来访的整体情况。
评估客户来访自上次会话以来的整体情绪。
与上一次会话衔接，询问你关心的任何问题。
回顾上一次会话的家庭作业。
确定可能的议程项目。

进一步的知识点阐述

解释会话结构的重要性：
- 增强舒适感：向客户来访解释会话的结构可以帮助他们感到更加舒适，因为他们会知道期待什么。
- 类比说明：将治疗比作访问一个外国国家，强调了解当地习俗的重要性，帮助客户来访理解为什么需要结构化。
结构化会话的关键组成部分：
- 检查：简短更新客户来访自上次会话以来的情况，确保与上次会话的衔接。
- 设定议程：与客户来访共同决定当前会话的重点问题，确保会话内容集中且有效。
- 执行议程：解决议程上确定的问题，确保会话内容集中且有效。
- 家庭作业：与客户来访合作为下一次会话开发家庭作业，确保客户来访在会话之间继续进步。
- 回顾：在会话结束时，简要回顾当前会话的内容，并征求客户来访的反馈，以便不断改进治疗效果。
实践建议：
- 新客户来访：向新客户来访解释会话结构时，明确说明每一步的目的，确保客户来访理解并接受。
- 现有客户来访：如果现有客户来访不习惯结构化会话，可以逐步引入，解释其好处，并征求客户来访的反馈。

让我们看看不同的组成部分

检查客户来访自上次会话以来的情况

你需要了解客户来访自上次会话以来是否有任何变化，以及他们的整体感受如何。如果客户来访的情绪发生了变化，无论是变好还是变坏，我会进一步询问发生了什么变化，或者客户来访是如何理解这种情绪变化的。

请客户来访评估她的情绪

我通常会让客户来访评估自上次会话以来的整体情绪。大多数非认知行为疗法（CBT）的治疗师不习惯评估情绪——尝试一下，看看你和你的客户来访是否会从中受益。使用1到10的评分标准，其中10表示客户来访感觉最糟糕，1表示非常快乐。评估有助于客户来访进行自我反思，也能让你快速了解客户来访的情况，判断他们是否比上次会话时更好、相同或更糟。

让我举一个快速的例子，说明评估客户来访情绪的益处。当我刚开始与唐纳德合作时，他的抑郁评分为10，我们甚至考虑是否需要住院治疗。经过大约六个月的治疗，唐纳德的情况显著改善，情绪评分通常在4到5之间。他离开了一段时间，我已经有两周没见他了。他在会话开始时说，过去两周他非常抑郁，害怕需要住院。他将自己的整体情绪评为8。意识到他是8而不是10让他感到不那么害怕，并能集中精力解决与抑郁加重相关的问题。

与上一次会话衔接

这是一个机会，跟进上一次会话中的任何问题，包括询问你担心的客户来访生活中的特定领域。例如，如果我有一个有自杀倾向的客户来访，我会在检查时询问当前的自杀念头和行为。如果客户来访正在处理某个特定问题，比如减少周末酗酒或停止自残，即使客户来访没有提到这些问题，我也会在检查时询问。这为治疗提供了连续性。

回顾家庭作业

检查是一个回顾家庭作业的好时机，尽管有些治疗师会在设定议程时回顾家庭作业。一项大型元分析研究（Mausbach, Moore, Roesch, Cardenas, & Patterson, 2010）发现，完成家庭作业与治疗的积极结果显著相关。这意味着我们需要尽一切努力鼓励客户来访完成家庭作业。询问和回顾家庭作业告诉客户来访家庭作业的重要性，并鼓励他们完成。

如果客户来访完成了家庭作业：给予正面反馈，并指出其重要性。检查客户来访实际做了什么以及结果如何。客户来访并不总是以你预期的方式理解家庭作业。然后，询问客户来访从家庭作业中学到了什么。
如果客户来访没有完成家庭作业：探讨是什么阻碍了他们。我通常会问客户来访未来有什么可以帮助他们完成家庭作业的方法。如果可能，我们会在会话中花一些时间完成家庭作业任务。在会话结束时，我会花额外的时间确保下周的家庭作业对客户来访来说是有意义的。在本章的后面，我们将讨论如何开发有效的家庭作业。

确定可能的议程项目

检查中提到的问题通常是治疗会话中值得讨论的好议题。例如，如果客户来访告诉你她正在考虑与男友分手，或者她又冲动地花了太多钱买衣服，你可以问：“这是你今天想讨论的事情吗？”或“这是我们应该放在议程上的事情吗？”重要的是要确认，因为有时当被问及时，客户来访会意识到这并不是他们真正想讨论的内容。

进一步的知识点阐述

检查客户来访的情况：
- 目的：了解客户来访自上次会话以来的变化和整体感受。
- 方法：询问客户来访是否有任何新的发展，以及他们的情绪变化。
评估客户来访的情绪：
- 评分标准：使用1到10的评分标准，10表示最糟糕，1表示非常快乐。
- 益处：帮助客户来访进行自我反思，让你快速了解客户来访的情况。
与上一次会话衔接：
- 目的：跟进上一次会话中的问题，确保治疗的连续性。
- 方法：询问客户来访生活中的特定问题，尤其是你担心的方面。
回顾家庭作业：
- 重要性：评估家庭作业的完成情况，鼓励客户来访完成家庭作业。
- 方法：给予正面反馈，探讨未完成的原因，确保家庭作业的意义。
确定可能的议程项目：
- 目的：将检查中提到的问题纳入议程，确保会话内容集中且有效。
- 方法：询问客户来访是否希望讨论这些问题，确认客户来访的意愿。

保持检查的简洁和聚焦

检查的挑战在于保持简短和聚焦。这意味着，当客户来访提出一个问题时，你不要立即深入探讨，而是需要控制客户来访，确保这是她希望在治疗会话中解决的问题。例如，假设在检查过程中，客户来访开始详细讲述她在孩子老师那里遇到的复杂问题，而你还没有设定议程。你可以说：“我觉得这是一个重要的话题。但在我们进一步讨论之前，我想确认一下这是否是你今天想关注的问题，还有没有其他问题。”如果你已经向客户来访解释过她将在会话开始时设定议程，她会觉得你停下来确认她想讨论的内容是正常的。她可能会说：“是的，这是主要问题。”在这种情况下，你就有了议程。检查是在充分了解问题以确保没有立即的危机和不让检查占用整个会话之间的平衡。

以下是一些我在检查过程中保持客户来访聚焦时发现有用的表达：

这听起来确实是个重要的问题。在我们进一步讨论之前，我想确认一下这周是否还有其他事情发生，或者你今天还想在治疗中提及其他问题。
这听起来确实很让人不安，进一步讨论也很重要。但在我们深入细节之前，我想了解一下自上次会话以来你的整体情况。
我能理解这会让你很不安。我会记下来，确保我们稍后会回到这个问题上，但我也想回顾一下我们上周讨论的内容。

当客户来访进来并开始谈论她生活中的一个重要情况时，很难不被吸引进入治疗过程，忘记完成检查或设定议程。你可以直接地说：“我刚意识到我们已经开始讨论这个问题了，但我还没有问你这是否是你今天主要想讨论的话题。”

注意事项：虽然认知行为疗法（CBT）会话遵循一定的结构，但重要的是要灵活并敏感地对待客户来访的需求。例如，如果客户来访在会话开始时因讲述刚刚发生的可怕事件而哭泣，当然不会严格遵守结构化的会话。我会同理地倾听，评估她的即时需求，并帮助她应对强烈的情绪。然而，在我听完发生了什么之后，如果客户来访冷静下来，我可能会说：“我想进一步讨论这个问题。但我也想确认一下你今天是否还有其他想讨论的问题。”我常常惊讶地发现，即使客户来访正处于危机中，她也可能有其他需要解决的问题。

进一步的知识点阐述

保持检查的简洁和聚焦：
- 挑战：检查过程中容易被客户来访的问题带偏，导致检查占用过多时间。
- 方法：确认客户来访是否希望在治疗会话中讨论这些问题，避免立即深入探讨。
- 平衡：既要充分了解问题，确保没有立即的危机，又要避免检查占用整个会话时间。
有用的表达：
- 确认其他问题：确保客户来访没有遗漏其他重要问题。
- 整体情况：了解客户来访自上次会话以来的整体情况。
- 回顾：回顾上一次会话的内容，确保连续性。
灵活性和敏感性：
- 重要性：尽管CBT会话有固定结构，但需要根据客户来访的具体需求灵活调整。
- 特殊情况：在客户来访情绪激动或处于危机中时，应优先处理即时需求。
- 确认议程：在处理完紧急情况后，仍然需要确认客户来访是否有其他需要讨论的问题。

通过这些技巧和注意事项，治疗师可以更好地管理检查过程，确保会话的有效性和客户来访的满意度。保持检查的简洁和聚焦不仅有助于治疗的顺利进行，还能确保客户来访的重要问题得到充分的关注和解决。

苏珊的治疗师从检查开始

让我们看一个检查如何进行的例子。这是苏珊的第四次会话，她的治疗师已经解释了使用结构化会话的方法。在阅读下面的对话之前，请问自己：你会如何开始这次会话？

治疗师：你好，很高兴见到你。我想先检查一下，了解一下你这一周的情况，列出你今天想关注的问题，并听听家庭作业的情况。

苏珊：（看起来很沮丧）嗯，这一周差不多一样，非常糟糕。我做了家庭作业，带来了。

苏珊的治疗师想跟进家庭作业，但也希望她评估一下自己的情绪，并继续进行检查。

治疗师：你做了家庭作业真是太好了；我想跟进一下，但首先我想了解一下你这一周的整体情况，看看我们今天需要关注什么。这样可以吗？（苏珊点头。）我想知道……如果你要评估你这一周的情绪，你会给它打多少分？

请注意，治疗师如何将苏珊重新引导到检查的任务上。

苏珊：大概整体上是7分；大部分时间我都感到非常沮丧。

治疗师：和上周一样。有没有特别难熬的时刻，或者情绪有所好转的时候？

苏珊：我不太确定，大部分时间都很沮丧。家里的情况还是老样子。我实在受不了新学校。我觉得老师们真的很差劲。不管我怎么努力，就是无法融入。（听起来更不安和烦躁。）有一位老师问我午餐时间都做些什么，因为她从未在食堂见过我。我不知道该说什么。

这个问题与苏珊的目标“尝试适应新学校”有关，可能是一个值得在治疗中关注的问题。然而，这并不是一个危机问题，其他问题可能更重要。请注意，治疗师并没有回应“当她问你午餐时间做什么时，你感觉如何？”或“再多告诉我一些”，因为这些回应会鼓励苏珊继续谈论这个事件。

治疗师：听起来老师的评论让你很不安。在我们进一步讨论之前，我想确认一下，这是你今天主要想谈的问题吗，还是有其他问题？

苏珊：这只是今天早上发生的事。我不想花时间在这个问题上；它不是那么重要。

在这个检查阶段，苏珊已经表示她的生活中没有发生变化，并评估了她整体的情绪。治疗师也没有需要从上次会话中引出的问题。下一步是讨论家庭作业并设定议程。

进一步的知识点阐述

检查的结构和目标：
- 简短和聚焦：检查的目的是快速了解客户来访一周的情况，确保没有紧急问题，同时确认客户来访希望在本次会话中讨论的主要问题。
- 评估情绪：通过让客户来访评估自己的情绪，治疗师可以更好地了解客户来访的状态，并根据情绪变化调整会话内容。
- 确认议程：检查完成后，治疗师和客户来访共同确定本次会话的议程，确保会话内容集中且有效。
有用的表达：
- 确认其他问题：确保客户来访没有遗漏其他重要问题。“在我们进一步讨论之前，我想确认一下，这是你今天主要想谈的问题吗，还是有其他问题？”
- 整体情况：了解客户来访自上次会话以来的整体情况。“我想了解一下你这一周的整体情况，看看我们今天需要关注什么。”
- 回顾：回顾上一次会话的内容，确保连续性。“我想确认一下，这是你今天主要想谈的问题吗，还是有其他问题？”
灵活性和敏感性：
- 重要性：尽管CBT会话有固定结构，但需要根据客户来访的具体需求灵活调整。
- 特殊情况：在客户来访情绪激动或处于危机中时，应优先处理即时需求。
- 确认议程：在处理完紧急情况后，仍然需要确认客户来访是否有其他需要讨论的问题。

轮到你了！

帮助拉乌尔在检查中保持专注

让我们看看拉乌尔的治疗师是如何进行检查的。

治疗师：你好，很高兴见到你。我想先检查一下，了解一下你这一周的情况，看看你今天想关注的问题，以及你的家庭作业情况。

拉乌尔：（看起来很焦虑）我这一周一直非常焦虑。我有一个重要的项目截止日期快到了，但我远远落后了。我的老板一定认为我是个彻底的失败者。我的焦虑达到了顶点。我不知道自己怎么了，我应该把项目做完。

请看下面三种可能的回应。选择一个能够帮助拉乌尔回答检查问题的回应。

我能理解你为什么会焦虑。你过去做得很好。你觉得为什么你的老板认为你是个失败者？
让我们看看能否帮你解决截止日期的问题。你需要做些什么来完成截止日期？
听起来我们有必要看看项目上发生了什么。但在我们这样做之前，我想确认一下这一周还有什么其他对你重要的事情发生。

选择第3个回应：这个回应帮助拉乌尔保持在检查的框架内，并展示了治疗师对项目紧迫性的同情。在第1个回应中，治疗师试图提供支持，但假设与老板的问题是主要议程，没有进行检查或设定议程。在第2个回应中，治疗师在不确定这是拉乌尔想关注的主题的情况下就开始解决问题。

治疗师：听起来我们有必要看看项目上发生了什么。但在我们这样做之前，我想确认一下这一周还有什么其他对你重要的事情发生。

拉乌尔：我太焦虑了，都没睡好觉，但除此之外没有什么新的事情。

在这种情况下，你有一个来自检查的议程项目。在开始讨论议程项目之前，你需要让拉乌尔评估他这一周的整体情绪，并确认是否有其他他想在治疗中讨论的问题。你只需要说：“在我们讨论项目中的困难之前，我想快速了解一下你这一周的整体情绪。你如何评估你的情绪，从1到10分？”

练习 4.1：尤莱拉度过了非常糟糕的一周

练习在客户来访有多重问题时保持检查的聚焦。

进一步的知识点阐述

检查的结构和目标：
- 简短和聚焦：检查的目的是快速了解客户来访一周的情况，确保没有紧急问题，同时确认客户来访希望在本次会话中讨论的主要问题。
- 评估情绪：通过让客户来访评估自己的情绪，治疗师可以更好地了解客户来访的状态，并根据情绪变化调整会话内容。
- 确认议程：检查完成后，治疗师和客户来访共同确定本次会话的议程，确保会话内容集中且有效。
有用的表达：
- 确认其他问题：确保客户来访没有遗漏其他重要问题。“在我们讨论项目中的困难之前，我想快速了解一下你这一周的整体情绪。你如何评估你的情绪，从1到10分？”
- 整体情况：了解客户来访自上次会话以来的整体情况。“我想确认一下这一周还有什么其他对你重要的事情发生。”
灵活性和敏感性：
- 重要性：尽管CBT会话有固定结构，但需要根据客户来访的具体需求灵活调整。
- 特殊情况：在客户来访情绪激动或处于危机中时，应优先处理即时需求。
- 确认议程：在处理完紧急情况后，仍然需要确认客户来访是否有其他需要讨论的问题。

议程项目 #3：协作设定议程

设定议程涉及与客户来访合作，列出她希望在会话中关注的问题。有些治疗师认为设定议程听起来像是商业会议，但实际上是非常以客户来访为中心的。当你设定议程时，你是在说：“我关心我们的治疗是否集中在对你重要的事情上，因此在会话开始时，我想花几分钟时间确认你想讨论的问题。”这一过程包括客户来访表达她的需求，而你作为治疗师，倾听并回应她的需求。这对客户来访来说是非常赋权的。

设定议程还设定了一个期望，即治疗不仅仅是来谈谈而已，你还希望客户来访专注于具体问题，并思考她想讨论的内容。作为治疗师，你也可以在议程中添加问题。例如，如果你与青少年的缓刑官或家长交谈过，这时可以让青少年知道，并将其添加到议程中。写出来并放在你们都能看到的地方是有帮助的。许多治疗师在办公室里有白板或翻页板，但你也可以使用一张纸。

清晰的议程  集中的治疗  有效的治疗和满意的客户来访

我喜欢设定议程的其中一个原因是，它有助于解决所谓的“门把手治疗”。门把手治疗是指会话结束时，客户来访手扶门把手准备离开时说：“哦，我忘了，我想和你谈谈这个非常重要的问题。”这时你可以回答：“这听起来像是一个重要的问题。我们可以在下次会话的议程中加入，并从这个问题开始讨论吗？”如果客户来访经常在治疗结束时提出重要问题，你可以在会话开始时说：“过去的几次会话中，直到结束时你才想起有重要的问题想讨论。我想，花点时间思考一下你今天想讨论的内容可能会有帮助。”随着客户来访学会为她的治疗会话设定议程，她不仅在承担治疗的责任，也在承担改变生活的责任。

一旦列出了议程项目，下一步是询问客户来访她希望从哪个问题开始。如果客户来访在议程上有许多问题，我会简单地说：“今天我们不可能讨论所有的问题。让我们选择两三个，看看能否开始处理它们。”决定每个问题的大致讨论时间也是有帮助的。在会话的中途，我通常会告知客户来访时间，并询问她是否希望继续讨论当前问题或转到议程上的下一个问题。

以下是一些有助于设定议程的有用问题。你可以在 http://www.newharbinger.com/38501 下载《帮助设定议程的问题》手册。

你今天希望关注什么问题？
我们今天应该把什么放在议程上？
我们是否应该列出你今天想讨论的问题，然后选择从哪里开始？

进一步的知识点阐述

设定议程的重要性：
- 客户来访为中心：通过设定议程，治疗师表明他们关心客户来访的需求，确保治疗内容集中在客户来访认为重要的问题上。
- 赋权客户来访：让客户来访表达自己的需求，使他们感到被尊重和重视，从而增强他们的自我效能感。
设定议程的过程：
- 客户来访表达需求：客户来访有机会表达他们希望在会话中讨论的问题。
- 治疗师倾听和回应：治疗师倾听客户来访的需求，并与客户来访一起确定议程项目。
- 共同决定：客户来访和治疗师共同决定哪些问题是最需要讨论的。
设定议程的好处：
- 避免“门把手治疗”：防止客户来访在会话即将结束时突然提出重要问题。
- 提高效率：确保会话内容集中，避免偏离主题。
- 增加客户来访满意度：客户来访感到他们的需求得到了关注，从而对治疗更加满意。
实用技巧：
- 写出来：将议程写出来并放在双方都能看到的地方，有助于保持会话的透明度和集中度。
- 时间管理：决定每个问题的大致讨论时间，确保会话高效进行。
- 灵活调整：在会话中途提醒客户来访时间，并根据实际情况灵活调整议程。

通过这些技巧和注意事项，治疗师可以更好地管理治疗会话，确保会话的有效性和客户来访的满意度。设定议程不仅有助于治疗的顺利进行，还能增强客户来访的参与感和责任感。

苏珊的议程

让我们看看苏珊的治疗师在完成检查后如何设定议程。如果你还记得，在苏珊的案例中，检查过程中没有出现议程项目。

治疗师：我想花几分钟时间列出你今天希望关注的问题。我还想确保我们花一些时间回顾家庭作业，但我想确认一下你是否有其他想要讨论的问题。

苏珊：其实，我今天主要想讨论的是校长邀请我去他家参加新教师烧烤聚会的事情。我非常焦虑，不确定是否应该去。

治疗师：这听起来像是一个重要的问题。你还有其他想要讨论的吗？

苏珊：其实，是的，这一周我对丈夫非常生气。他答应周末照顾孩子，结果却去工作了。这是我今天想讨论的两个主要问题。

这两个问题都与苏珊的目标相关。只是需要确定哪一个对她来说更重要。

治疗师：在烧烤聚会和对丈夫的愤怒之间，你希望从哪个问题开始？

苏珊：我想从烧烤聚会开始，因为我对此非常担心。对丈夫的愤怒问题感觉没有那么急迫。

治疗师：我们先回顾一下家庭作业，然后花一些时间讨论烧烤聚会的邀请，如果有时间的话，再讨论你对丈夫的愤怒，这样可以吗？

苏珊：听起来不错。

进一步的知识点阐述

设定议程的重要性：
- 客户来访为中心：通过设定议程，治疗师确保会话内容集中在客户来访认为重要的问题上，体现了对客户来访的尊重和关注。
- 赋权客户来访：让客户来访表达自己的需求，并决定讨论的顺序，增强了客户来访的参与感和责任感。
设定议程的过程：
- 确认客户来访的需求：治疗师询问客户来访希望讨论的问题，确保没有遗漏。
- 共同决定：客户来访和治疗师共同决定哪些问题是最需要讨论的，并确定讨论的顺序。
- 灵活调整：根据实际情况灵活调整议程，确保会话的高效和有序。
设定议程的好处：
- 提高效率：确保会话内容集中，避免偏离主题。
- 增加客户来访满意度：客户来访感到他们的需求得到了关注，从而对治疗更加满意。
- 避免“门把手治疗”：防止客户来访在会话即将结束时突然提出重要问题。
实用技巧：
- 写出来：将议程写出来并放在双方都能看到的地方，有助于保持会话的透明度和集中度。
- 时间管理：决定每个问题的大致讨论时间，确保会话高效进行。
- 回顾家庭作业：确保家庭作业的回顾是议程的一部分，强调其重要性。

拉乌尔的议程

拉乌尔在检查中提到了一个议程项目。他的治疗师想确认他是否还有其他希望在会话中讨论的问题。

治疗师：我想列出我们今天希望关注的问题。你提到的一个问题是即将到来的项目截止日期；你还有其他希望讨论的问题吗？

拉乌尔：其实，我妻子想邀请她姐姐来我们家住一个月，以便找工作。我非常生气——如果她姐姐找了很长时间的工作怎么办？我们不能让她随便搬进来，但又不能拒绝，毕竟是家人。她姐姐是个很难相处的人，总是滔滔不绝。她期望我们照顾她。

治疗师：听起来讨论你妻子的姐姐可能搬进来的问题也很重要。我只想确认一下，还有其他问题吗？

注意，治疗师总结了问题，表明她听到了拉乌尔的担忧，但仍然坚持设定议程。

拉乌尔：这两个问题。说实话，我姐夫住进来这个主意并不好。她很挑剔，我觉得她不太喜欢我。她还经常贬低我妻子。

虽然很想开始讨论拉乌尔的姐夫，但我们还没有问他希望从哪个问题开始。

治疗师：我们有两个大问题；你希望从哪个问题开始，工作中的项目还是你姐夫？

拉乌尔：我想从项目开始，因为如果完不成这个项目，我可能会再次受到负面评价！这一切压力太大了。

治疗师：确实压力很大。那我们就从项目开始吧。我会在会话进行到一半时告诉你，然后我们可以讨论你姐夫的问题。

注意，治疗师坚持结构，但加入了共情的评论“确实压力很大”，表明她理解了拉乌尔的困扰。

议程项目 #4：执行议程

一旦设定了议程并决定了第一个项目，下一步就是在治疗中开始处理这个问题。其中一个挑战是坚持议程项目。根据我的经验，治疗过程中很容易偏离主题。例如，客户来访可能开始谈论她对批评她育儿方式的父亲的愤怒，然后转向谈论她对即将搬家的表亲的感受。很容易偏离议程。当你和朋友聊天时，话题会从一个跳到另一个；但在治疗中，你希望专注于一个具体的问题。

保持客户来访专注的最简单方法是指出她偏离了议程，并询问她希望怎么做。你可以温和地说：“我们在谈论你对父亲的感受，现在转移到了谈论你的表亲。我想知道你是希望回到讨论父亲，还是觉得与表亲的问题更重要。”这样，你给了客户来访选择的机会。然而，保持灵活性也很重要。如果客户来访开始谈论一个她难以讨论的痛苦问题，或披露了一个创伤性或非常令人不安的事件，你应该跟随客户来访的引导。

练习 4.2：德伟再次吸食大麻

练习保持结构化的会话。

视频 4.1：检查和设定议程

进一步的知识点阐述

设定议程的重要性：
- 客户来访为中心：通过设定议程，治疗师确保会话内容集中在客户来访认为重要的问题上，体现了对客户来访的尊重和关注。
- 赋权客户来访：让客户来访表达自己的需求，并决定讨论的顺序，增强了客户来访的参与感和责任感。
设定议程的过程：
- 确认客户来访的需求：治疗师询问客户来访希望讨论的问题，确保没有遗漏。
- 共同决定：客户来访和治疗师共同决定哪些问题是最需要讨论的，并确定讨论的顺序。
- 灵活调整：根据实际情况灵活调整议程，确保会话的高效和有序。
设定议程的好处：
- 提高效率：确保会话内容集中，避免偏离主题。
- 增加客户来访满意度：客户来访感到他们的需求得到了关注，从而对治疗更加满意。
- 避免“门把手治疗”：防止客户来访在会话即将结束时突然提出重要问题。
执行议程的挑战：
- 保持专注：治疗过程中容易偏离主题，需要治疗师及时引导客户来访回到议程项目。
- 共情和支持：在指出客户来访偏离议程时，治疗师应保持共情和支持，避免让客户来访感到被指责。
- 灵活性：如果客户来访开始讨论一个痛苦或创伤性的问题，治疗师应跟随客户来访的引导，提供必要的支持。
实用技巧：
- 写出来：将议程写出来并放在双方都能看到的地方，有助于保持会话的透明度和集中度。
- 时间管理：决定每个问题的大致讨论时间，确保会话高效进行。
- 回顾家庭作业：确保家庭作业的回顾是议程的一部分，强调其重要性。

通过这些技巧和注意事项，治疗师可以更好地管理治疗会话，确保会话的有效性和客户来访的满意度。设定议程和执行议程不仅有助于治疗的顺利进行，还能增强客户来访的参与感和责任感。

议程项目 #5：为下一次会话制定有益的家庭作业

家庭作业是客户来访在日常生活中实践治疗中所学内容的机会。在一项元分析研究中，Kazantzis、Whittington 和 Dattilio（2010）发现，总体而言，当治疗包含家庭作业时，62% 的客户来访有所改善，而当治疗不包含家庭作业时，只有 38% 的客户来访有所改善。对我来说，这是一个相当有说服力的理由，要在治疗中包含家庭作业。

家庭作业可以有多种形式。一些例子包括：注意客户来访在特定情境下的困难，要求客户来访完成思维记录，或要求客户来访尝试新的行为。

完成家庭作业的客户来访往往从治疗中受益更多（Rees et al., 2005）。那么，如何增加客户来访完成家庭作业的可能性呢？首先，确保在会话结束前留出5到10分钟来计划家庭作业。匆匆布置的任务往往不会被执行。其次，使用以下四个标准来制定有益的家庭作业。你可以在 http://www.newharbinger.com/38501 下载《有益家庭作业指南》手册。

与客户来访协作制定
具体且明确
与会话相关
可行

与客户来访协作制定

理想情况下，家庭作业是通过与客户来访的讨论得出的。我通常会问：“你认为在接下来的一周里，怎样才能很好地实践我们今天讨论的内容？”虽然客户来访可能会有一些好的建议，但通常是治疗师提出具体的家庭作业。重要的是要检查客户来访对任何建议的家庭作业的反应。我通常会说：“我有一个想法，那就是……你觉得怎么样？”我的客户来访经常会有一些关于如何修改我的建议的好主意。

具体且明确

你和客户来访需要清楚地知道她将要做什么家庭作业。为了判断家庭作业是否具体且明确，可以问自己：客户来访将尝试的具体行为是什么？客户来访多久做一次家庭作业？客户来访在哪里和何时做家庭作业？例如，“注意你的消极思想”并不是非常具体或明确。一个更具体的任务是：“当你在科学课上对老师感到生气时，写下你心中的想法。你认为这周你能做到两次吗？”这样，客户来访就知道她要做什么、在什么情况下做以及频率是多少。

除非家庭作业具体且明确，否则客户来访无法准确评估她是否完成了家庭作业。例如，拉乌尔的家庭作业是开始他一直在回避的一个小组项目。在下一次会话中，拉乌尔报告说他已经联系了他的同事并安排了下周二的会议。拉乌尔补充道：“我没有完成家庭作业；我本应该已经开始项目的。”如果他的家庭作业是联系同事并安排会议，拉乌尔的反应可能会不同。

与会话相关

客户来访更有可能完成与会话相关的家庭作业。让我们回到苏珊的例子。她的一次会话重点是识别她在学校遇到的具体困难情境。听放松磁带不是一个有效的家庭作业任务。虽然她可能会觉得磁带有帮助，但它与她在会话中讨论的内容无关。一个更好的家庭作业任务是与她在学校遇到的困难情境相关的活动。有效的家庭作业也与客户来访的总体目标相关。

可行

确保询问客户来访家庭作业是否可行，以及她是否预见到了任何障碍。如果客户来访预见到了障碍，可以帮助她找到克服这些障碍的方法。

进一步的知识点阐述

家庭作业的重要性：
- 实践机会：家庭作业为客户来访提供了在日常生活中实践治疗中所学内容的机会。
- 提高疗效：研究表明，包含家庭作业的治疗效果更好，客户来访更有可能从中受益。
制定家庭作业的标准：
- 与客户来访协作制定：通过与客户来访的讨论来制定家庭作业，确保客户来访对其内容感到认同和接受。
- 具体且明确：家庭作业必须具体且明确，以便客户来访能够准确执行并评估完成情况。
- 与会话相关：家庭作业应与会话内容和客户来访的总体目标相关，以增强其实际效果。
- 可行：确保家庭作业是可行的，帮助客户来访克服可能的障碍，增加完成的可能性。
实用技巧：
- 留出时间：在会话结束前留出5到10分钟来计划家庭作业，确保任务的详细和具体。
- 检查反应：询问客户来访对家庭作业的反应，确保任务的可行性。
- 灵活调整：根据客户来访的反馈灵活调整家庭作业，使其更符合客户来访的需求。

通过这些技巧和注意事项，治疗师可以更好地制定和管理家庭作业，确保客户来访在日常生活中能够有效应用治疗中的学习成果，从而提高治疗的整体效果。

轮到你了！

评估苏珊的家庭作业

在第6次会话中，苏珊谈到了她几乎停止了所有曾经与孩子们一起享受的活动。苏珊在会话中非常悲伤和自我批评，常常流泪。在会话即将结束时，苏珊叹了口气，说：“我已经成了一个糟糕的母亲。我真的很想重新和孩子们做一些有趣的事情。”苏珊的治疗师回应说：“我想给你布置一些家庭作业。我认为如果你能在接下来的一周里尝试和孩子们做一些有趣的事情，将会非常有帮助。”这项家庭作业是否符合有益家庭作业的指导原则？请完成下面的表格。你可以在附录中找到我的答案。

有益家庭作业指导原则

有益家庭作业指导原则	苏珊的家庭作业是否符合此指导原则
家庭作业是与客户来访协作制定的
家庭作业具体且明确
家庭作业与会话相关
家庭作业可行

在查看下面的对话之前，你可以问苏珊哪些问题，以便你们一起制定符合指导原则的家庭作业？

治疗师：我们还有大约五分钟的时间。你说你希望重新开始和孩子们做一些你以前喜欢的有趣活动。这是否给你带来了任何关于本周家庭作业的想法？

重要提示：当会话剩余至少五分钟时，开始制定家庭作业是很重要的。注意，治疗师首先询问苏珊是否有任何想法。

苏珊：没有，真的没有。

治疗师：我在想，你能否想到一个你以前和孩子们一起做的活动，希望在这一周重新开始做。

如果苏珊能想到一个活动，他们将共同制定一个具体的计划，包括活动何时进行以及苏珊具体要做什么。治疗师会检查这个计划是否可行，苏珊是否具备完成家庭作业所需的一切。最后，治疗师会检查是否有任何障碍。

苏珊和她的治疗师决定，她将在周一和周三晚上的晚餐前，坐在沙发上和孩子们一起看十分钟电视。这项家庭作业是否协作制定、具体明确、与会话相关且可行？我认为是的。

治疗师：我不想让客户来访觉得自己失败了，如果她没有完成家庭作业或者进展不顺利。我通常在讨论家庭作业结束时说：“如果你完成了家庭作业，那非常好，这将帮助我们看到你如何开始朝着目标前进。如果你没有完成家庭作业，重要的是我们要探讨发生了什么，这将给我们一些线索，了解是什么让你陷入困境。”

练习 4.3

练习使用家庭作业指导原则。

进一步的知识点阐述

家庭作业的重要性：
- 实践机会：家庭作业为客户来访提供了在日常生活中实践治疗中所学内容的机会。
- 提高疗效：研究表明，包含家庭作业的治疗效果更好，客户来访更有可能从中受益。
制定家庭作业的标准：
- 与客户来访协作制定：通过与客户来访的讨论来制定家庭作业，确保客户来访对其内容感到认同和接受。
- 具体且明确：家庭作业必须具体且明确，以便客户来访能够准确执行并评估完成情况。
- 与会话相关：家庭作业应与会话内容和客户来访的总体目标相关，以增强其实际效果。
- 可行：确保家庭作业是可行的，帮助客户来访克服可能的障碍，增加完成的可能性。
实用技巧：
- 留出时间：在会话结束前留出5到10分钟来计划家庭作业，确保任务的详细和具体。
- 检查反应：询问客户来访对家庭作业的反应，确保任务的可行性。
- 灵活调整：根据客户来访的反馈灵活调整家庭作业，使其更符合客户来访的需求。

议程项目 #6：回顾会话并征求反馈

结构化会话的最后一部分涉及回顾会话并征求反馈。这部分经常被遗忘或匆忙处理，但与其他组成部分一样重要。

回顾会话

帮助客户来访记住治疗中所涵盖内容的最佳方法之一是让他们回顾。如果他们忘记了你认为重要的某个点，你可以提出并询问这是否也对他们很重要。许多客户来访会记笔记，要么在会话中，要么在会话结束时写下他们想记住的要点。在我的临床记录中，我也会写下回顾的主要内容。以下是一些有助于引入回顾治疗会话的方式。你可以在 http://www.newharbinger.com/38501 下载《回顾治疗会话的问题》手册。

在我们结束前，让我们花点时间回顾一下。你认为今天会话中最重要的是什么？
在我们结束会话前，让我们花点时间思考一下今天讨论的内容。我认为我们讨论了一些非常重要的事情，我希望我们不要忘记它们。你能否写下任何你希望记住的内容？
我觉得停下来总结一下我们讨论的内容会有帮助。你能否用自己的话概括我们讨论的内容？

几年前，我注意到如果我觉得会话进行得不顺利，我会“忘记”回顾，或者方便地时间不够。当我开始即使觉得会话进行得不顺利也要回顾时，我发现很多时候客户来访觉得会话是有帮助的。这是非常有用的信息。如果客户来访觉得会话没有帮助，这也是有价值的信息。我们现在有了一个可以讨论和潜在解决的问题，而不是让我担心会话的效果。

进一步的知识点阐述

回顾会话的重要性：
- 帮助记忆：通过回顾，客户来访可以更好地记住治疗中所讨论的内容，巩固学习成果。
- 确认重点：回顾有助于确认哪些内容对客户来访来说最重要，确保客户来访对关键点的理解。
- 提供反馈：回顾是一个收集客户来访反馈的好机会，了解客户来访对会话的看法和感受。
回顾会话的方法：
- 提问引导：通过提问引导客户来访回顾会话内容，确保客户来访积极参与。
- 记录要点：鼓励客户来访记笔记，记录他们希望记住的要点，有助于后续的复习和实践。
- 总结归纳：治疗师可以总结会话的主要内容，并询问客户来访是否同意这些总结。
实用技巧：
- 留出时间：在会话结束前留出足够的时间进行回顾，确保回顾过程充分。
- 保持开放：即使觉得会话进行得不顺利，也要进行回顾，保持开放的态度，听取客户来访的反馈。
- 灵活调整：根据客户来访的反馈灵活调整回顾的方式，确保客户来访感到舒适和参与。

通过这些技巧和注意事项，治疗师可以更好地管理和实施会话的回顾部分，确保客户来访能够有效地回顾和吸收治疗中的内容，从而提高治疗的整体效果。

向客户来访征求反馈

在回顾会话之后，是征求客户来访反馈的好时机。这在治疗关系的初期尤其重要。我通常会说：“我想确认一下，我们是否走在正确的道路上”或者“我想确认一下，我们做的哪些事情对你特别有帮助。有没有你觉得不是很有用的时间？”

轮到你了！

在想象中练习：与客户来访回顾会话

选择一个你目前正在治疗的客户来访，你认为他会愿意回顾会话。在我们开始之前，请从1到10评估你向客户来访提出回顾会话的舒适程度，1表示非常舒适，10表示非常不舒服。练习结束后，再次评估你的舒适程度，看看是否有变化。现在，让我们开始练习。

想象你现在在一个会话的末尾，你希望向客户来访提出回顾会话的要求。尽量在脑海中想象他的样子。想象自己在办公室里，花一点时间环顾四周，注意房间里的声音和气味。在想象中阅读《回顾治疗会话的问题》，同时也可以使用你自己的表达方式。真正听到并感受到自己在介绍回顾的概念。然后想象与同一个客户来访再回顾两次，每次想象客户来访都给予积极的回应。

视频 4.2：回顾会话并征求反馈

家庭作业：练习认知行为疗法

在继续下一章之前，花一些时间尝试以下家庭作业。

将所学应用于临床案例

完成以下练习。

练习 4.1：尤莱拉度过了一周非常糟糕的日子
练习 4.2：德伟再次吸食大麻
练习 4.3：(a) 丽妮试图在学校赶上进度，(b) 威尔逊感到紧张

将所学应用于自己的生活

我们大多数人在每天早上醒来时，都会有一长串要做的事情。我们需要优先考虑并确定对我们最重要的事情，否则就什么都做不成。在治疗中设置议程类似于在生活中确定最重要的事情。

家庭作业 #1：在生活中使用结构

议程是一个帮助客户来访识别和优先处理最重要的事情的列表。许多人通过列清单来帮助组织生活，确定首先需要完成的事情。我认为反思你自己的列清单经验和确定优先事项的经历会对你的治疗有所帮助。

考虑你生活中的清单：
- 花一点时间回想一个时候，列清单对你有帮助，以及一个时候，列清单对你没有帮助。
- 确定哪些因素使清单对你有帮助，哪些因素使清单对你没有帮助。
思考接下来的几天：
- 列出接下来几天你需要完成的不在常规范围内的事情，可以是工作或个人生活中的。
- 完成清单后，挑选三个优先完成的项目。尽量使这些项目具体且明确。
思考这次练习：
- 考虑这次练习是否有任何启示，可以帮助你在治疗中更有效地设置议程。现在花一点时间回顾你所学到的内容。

将所学应用于你的治疗实践

我想探讨你对使用结构化格式的期望和任何担忧。

进一步的知识点阐述

征求反馈的重要性：
- 确认方向：通过征求反馈，治疗师可以确认治疗的方向是否正确，是否满足客户来访的需求。
- 增强信任：征求反馈可以增强客户来访对治疗师的信任，让客户来访感到被重视和尊重。
- 改进治疗：客户来访的反馈可以帮助治疗师改进治疗方法，提高治疗效果。
征求反馈的方法：
- 简单明了：用简单明了的语言向客户来访提出反馈请求，确保客户来访理解你的意图。
- 开放性问题：使用开放性问题，鼓励客户来访提供详细的反馈。
- 积极倾听：认真倾听客户来访的反馈，表现出真诚的关注和尊重。
实用技巧：
- 留出时间：在会话结束前留出足够的时间征求反馈，确保反馈过程充分。
- 保持开放：即使客户来访提出批评，也要保持开放的心态，将其视为改进的机会。
- 灵活调整：根据客户来访的反馈灵活调整治疗计划，确保治疗的有效性。

通过这些技巧和注意事项，治疗师可以更好地管理和实施会话的反馈部分，确保客户来访能够有效地提供反馈，从而提高治疗的整体效果。

家庭作业 #2：探索你对使用结构化格式的态度

选择两位你目前正在合作的客户来访。想象在每位客户来访的会话中设置议程并在会话结束时进行回顾。我将要求你写下你的预测。为每位客户来访完成以下表格。

我的客户来访会：
- 1 2 不喜欢使用结构
- 3 4 有中立反应
- 5 喜欢使用结构
我会：
- 1 2 不喜欢使用结构
- 3 4 有中立反应
- 5 喜欢使用结构

我想象会发生的情况：

我对使用结构化格式与这位客户来访的主要担忧是：

家庭作业 #3：与新客户来访和现有客户来访结构化会话

选择两位客户来访，你将尝试与他们结构化会话。如果可能的话，选择一位新客户来访和一位你目前没有使用结构化会话的现有客户来访。如果你先单独练习不同的组成部分，然后再将它们组合起来，你更有可能学会新技能。我希望你从结构化会话的三个组成部分开始练习：（1）解释治疗会话的结构，（2）设置议程，（3）选择一个议程项目作为焦点。以下是三个步骤：

解释治疗会话的结构：向客户来访解释你希望列出她希望讨论的内容。你可以回顾本章，了解如何向新客户来访和现有客户来访介绍设置结构的方法。记住，设置议程只需说：“我想列出你今天希望讨论的内容。”如果是第一次尝试设置议程，你可能会发现手边有一份《解释治疗会话的结构》的手册会很有帮助。
设置议程：一旦你和客户来访设定了议程并确定了他或她希望关注的问题，把这些问题写下来，让你们都能看到。
选择一个议程项目：一旦你有了议程项目的列表，询问客户来访他或她希望从哪个项目开始。

如果你是在与现有客户来访设置议程，会话结束时询问客户来访是否喜欢设置议程。你可以说：“我很想知道你是否喜欢今天我们使用的这种结构，我们列出了你希望解决的问题。”如果客户来访有积极的反应，询问她是否希望在未来继续使用这种结构。

在你第一次尝试设置议程后，注意你对自己和客户来访反应的预测是否准确。花点时间思考你学到了什么。你的预测是否有所改变？

进一步的知识点阐述

探索态度的重要性：
- 预测反应：通过预测客户来访和自己的反应，治疗师可以更好地准备应对可能的情况，减少不确定性和焦虑。
- 识别担忧：明确自己的担忧可以帮助治疗师更有针对性地解决问题，提高治疗的自信和效果。
结构化会话的步骤：
- 解释结构：向客户来访解释会话的结构，确保客户来访理解并接受这种做法。
- 设置议程：与客户来访一起列出希望讨论的问题，确保议程清晰且具体。
- 选择议程项目：与客户来访一起选择一个议程项目作为焦点，确保会话的高效和有序。
实用技巧：
- 逐步练习：先单独练习不同的组成部分，然后再将它们组合起来，有助于逐步掌握新技能。
- 反馈和调整：在会话结束时征求客户来访的反馈，根据反馈调整方法，确保客户来访感到满意。
- 持续改进：通过反复练习和反思，不断改进自己的技能，提高治疗的效果。

通过这些技巧和注意事项，治疗师可以更好地管理和实施结构化会话，确保客户来访能够有效地参与治疗，从而提高治疗的整体效果。

家庭作业 #4：与客户来访回顾会话

一旦你已经尝试与两位客户来访设置议程，我希望你再加入结构化会话的一个组成部分。

在会话结束时，询问客户来访回顾会话。记住，你只需要问：“当你回顾我们今天的讨论时，你希望记住什么？”像上次练习一样，注意你对自己和客户来访反应的预测是否准确。

让我们回顾一下

回答以下议程项目下的问题。

议程项目 #1：组织你的治疗会话

结构化治疗会话的主要组成部分有哪些？
每个组成部分的重要性是什么？

议程项目 #2：从检查开始

检查中包含哪些内容？

议程项目 #3：协作设置议程

如何向新客户来访介绍设置议程？
如何向现有客户来访介绍设置议程？

议程项目 #4：执行议程

当客户来访偏离议程主题时，你该如何回应？

议程项目 #5：为下一次会话制定有益的家庭作业

有益的家庭作业的两个指导原则是什么？

议程项目 #6：回顾会话并征求反馈

你如何询问客户来访回顾会话？

你认为重要的内容

你希望记住哪些想法或概念？
你希望应用到自己生活中的哪些想法或技能？
你希望在接下来的一周内与哪位客户来访尝试什么？（选择一位具体的客户来访。）

进一步的知识点阐述

组织治疗会话的重要性：
- 主要组成部分：结构化治疗会话的主要组成部分包括检查、设置议程、执行议程、制定家庭作业、回顾会话和征求反馈。
- 每个组成部分的重要性：
  - 检查：帮助客户来访回顾上次会话后的进展，设定本次会话的基调。
  - 设置议程：确保会话有明确的目标和方向，提高效率。
  - 执行议程：集中讨论客户来访最关心的问题，确保会话的高效和有序。
  - 制定家庭作业：帮助客户来访在日常生活中实践所学内容，巩固治疗效果。
  - 回顾会话：帮助客户来访记住会话中的重要内容，确认治疗的方向。
  - 征求反馈：增强客户来访的参与感，改进治疗方法。
从检查开始：
- 检查内容：包括客户来访的情绪状态、最近的进展、遇到的挑战等，帮助客户来访和治疗师快速进入状态。
协作设置议程：
- 向新客户来访介绍：解释结构化会话的好处，说明设置议程的目的和方法。
- 向现有客户来访介绍：强调设置议程的必要性，解释如何进行，确保客户来访理解并接受。
执行议程：
- 应对偏离：当客户来访偏离议程主题时，可以通过温和的提醒和引导，帮助客户来访回到正题。
制定有益的家庭作业：
- 两个指导原则：
  - 具体且明确：家庭作业必须具体且明确，确保客户来访能够准确执行。
  - 与会话相关：家庭作业应与会话内容和客户来访的总体目标相关，增强实际效果。
回顾会话并征求反馈：
- 询问方法：通过开放性问题，鼓励客户来访提供详细的反馈，例如：“当你回顾我们今天的讨论时，你希望记住什么？”

通过这些技巧和注意事项，治疗师可以更好地管理和实施结构化会话，确保客户来访能够有效地参与治疗，从而提高治疗的整体效果。

CHAPTER 4 Structure Your Sessions Did you have a chance to try setting goals with a new or current client? Did you try any other home- work assignments from previous chapters? When you think of the interventions that you’ve tried, what would you like to continue doing? If you did not have a chance to try setting goals, take a moment and identify what obstacles got in the way. Choose a specific client you will see this coming week who you think would be open to setting goals. Now imagine yourself in your office setting goals with this client, and then try it! Set the Agenda We have identified your client’s problems, taken a history, explained the CBT model, and set goals. This usually takes between one and two sessions. You are now ready to start addressing your client’s problems. In this chapter, I want to focus on how to structure or organize your therapy sessions. Agenda Item #1: Organize your therapy sessions. Agenda Item #2: Start with a check-in. Agenda Item #3: Collaboratively set an agenda. Agenda Item #4: Work the agenda. Agenda Item #5: Develop helpful homework for the next session. Agenda Item #6: Review the session and ask for feedback. Work the Agenda Research shows that having a structure, and in particular setting an agenda, keeping to the agenda, and giving homework are key factors in effective therapy (Shaw et al., 1999). Many of my students tell me that structuring a session is one of the most helpful CBT skills that they learned; I think you will also find it helpful.

Agenda Item #1: Organize Your Therapy Sessions A structured session means that there is an order and organization to the therapy session. Here is a brief overview of the five basic components. I will go over each one in more detail later in the chapter.

Check in. This is a quick update on what has happened since the previous session and includes a bridge to the previous session.
Set the agenda. You and your client decide together which problems to focus on in the current session. Homework from the previous session can be reviewed during the check-in or as part of the agenda-setting process.
Work the agenda. This involves addressing the identified problems on the agenda.
Homework. You and your client collaborate to develop homework for the following session.
Review. At the end of the session you briefly review with your client what was covered in the current session and ask your client for feedback. At first, covering all of these components in one session may seem like a lot. However, once you get used to using a structure, it will flow naturally; my prediction is that you will wonder how you ever worked any other way. Learning to use a structure is similar to learning to drive a car. When I first learned to drive I was quite overwhelmed with how much I had to do all at once. I remember the first time I parked my parents’ car in the garage. I was so focused on not putting too much pressure on the gas, remembering where the brake was, and making sure that I did not hit anything on the right side that I scratched the whole left side of the car on the garage wall. I didn’t even have the necessary reflexes to hit the brake. With practice, driving became easy; and, you will be happy to know, I have not smashed into any walls in years! Just as driving is now a routine activity for me, using a structure will feel like the normal way of working once you have practiced with a few clients. YOUR ATTITUDE TOWARD A STRUCTURED SESSION Some therapists immediately like the idea of a structured session; others have negative reactions such as I will find a structure too rigid, My clients won’t like it, and It will interrupt the flow of therapy. However, I believe that after you try structuring sessions with a few clients you will start to think, Structure gives my therapy more focus, and My clients will like having a chance to let me know what they want to focus on. Take a moment to notice your own thoughts about using a structure. EXPLAIN THE STRUCTURE OF THE THERAPY SESSION TO YOUR CLIENT Explaining the structure of a therapy session will help your client feel more comfortable, as she will know what to expect. I think of therapy as similar to visiting a foreign country. If you don’t know the customs, and you don’t know what to expect, you will be uncomfortable. When I was in my twenties I spent a year in Indonesia. I remember the first time I went to an Indonesian wedding. I walked into the room, looked around, and had absolutely no idea what to do. To say the least, I felt very awkward. I can still remember my relief when my friend who had invited me took my arm, gently sat me down, and explained what was going to happen and what I needed to do. Explaining the structure of therapy is similar to explaining the customs of a foreign country. Your clients will be more relaxed and trusting if they know what to expect. You can find a Explain the Structure of a Therapy Session handout at http:// www.newharbinger.com/38501. Explain the structure of a therapy session with a new client. Here is an example of how you can explain structuring a session to a new client. I explain both what I am going to do and why. We’ve spent some time getting an idea of your problems and setting goals for therapy. I want to explain how I’d like to structure the actual therapy sessions. Each week when you come in I want to start with a brief check-in so that you can bring me up to date on anything that has happened in your life since our last session and we can get a sense of how you are doing. Then I want to make a list of what you would like to talk about during our therapy session. I find this helps make our sessions more focused, and that way I can be sure that we talk about what is most important for you. I call this setting an agenda. Often you and I will have decided on some homework that you are going to try in between sessions. If you had any homework, I will check on how it went. At the end of the session, we’ll spend some time summarizing what we’ve covered and make sure that we are on the right track for you. We will also see if there is any homework that makes sense for you to try before our next session. How does that sound to you? Most clients just say “Fine,” after which I say, “Let’s start. Could you bring me up to date on how your week has been and then we can see what you would like to focus on today?” With a new client, this is a straightforward process, and it almost always goes smoothly. Explain the structure of a therapy session with a current client. If you have not been using a struc- tured format, you may feel awkward about introducing a structure with a current client. Here is an example of how you could begin. I’ve been thinking about our sessions, and I would like to try something new today. I thought we would start with a brief check-in, so that you can bring me up to date on anything that has happened in your life since our last session and we can get a sense of how you are doing. I would then like to make a list of what you would like to focus on during our therapy session today and decide which issue you would like to start with. I think this will help focus our ses- sions, and that way I can be sure that we talk about what is most important for you. At the end we’ll spend some time summarizing what we covered and see how you liked working this way. Notice I am very clear about what we will do and that I will check whether my client likes this new way of working. My guess is that almost all of your clients will find having a structure helpful. Once you have explained setting a structure, it becomes a normal part of therapy. Clients who are used to the structure tend to spend time before the session thinking about what they want to talk about. Therapy becomes more focused; clients usually come in with one or two agenda items. When a client is used to a structured format, I start with, “Hello, good to see you. I want to check in and see how you have been doing, see what you would like to focus on today, and check how your homework went.”

Your Turn! Practice in Your Imagination: Explain How a Session Is Structured I would like you to imagine explaining how a session is structured, first with a new client and then with a current client. Before you start this exercise, rate from 1 to 10 how comfortable you feel explaining structuring a session with both a new and a current client, with 1 being very comfortable and 10 being very uncomfortable. At the end of the exercise, rate your level of comfort again to see if it has changed. Now, let’s try the exercise. Practice with a new client. Imagine yourself in your office with a new client. Take a moment to look around; notice the sounds and smells in the room. Now imagine you want to explain how you would like to structure the sessions. Read over how I explain structuring a session with a new client while imagining yourself saying it. You can also use your own phrases. Really hear and feel yourself explaining how you want to structure the therapy sessions. Now imagine explaining how you want to structure a session two more times with the same client. Each time imagine that your client responds positively. Practice with a current client. Choose a current client who you think would benefit from, and would like, a structured approach. Try to get a picture of him or her in your mind. Now, imagine yourself in your office. Read over how I explain structuring a session with a current client while imagining yourself saying it. You can also use your own phrases. Now imagine explaining setting a structure two more times with the same client. Each time imagine that your client responds positively. Agenda Item #2: Start with a Check-In The check-in is an opportunity to get a general sense of how your client is doing, find out if there have been any new developments in her life, and check on any issues that were raised in the last session. That way, if there have been any major events, or changes in your client’s life, you know about them right from the beginning of the session. Below is a review of the main components of the check-in that are covered in most sessions. Depending on the flow of the session, you may not necessarily complete the components in the order below. •Check whether there are any new developments in your client’s life and generally how your client has been since the last session. •Rate your client’s overall mood since the previous session. •Bridge to the last session and ask about any issues you are concerned about. •Review the homework from the last session. •Identify possible agenda items.

Let’s look at the different components. Check how your client has been since the last session. You want to know if there have been any changes since the last session and generally how your client has been feeling. If there has been a change in my client’s mood, either for better or worse, I follow up with asking whether anything has changed or how my client understands the change in her mood. Ask your client to rate her mood. I usually ask my clients to rate their overall mood since the last session. Most non-CBT therapists are not used to rating moods—try it and see whether you and your clients find it helpful. Use a scale of 1 to 10, with 10 being the worst your client has ever felt, and 1 being very happy. Rating helps your client engage in a process of self-reflection. It also gives you a quick sense of how your client is doing and if she is better, the same, or worse since the last session. Let me give you a quick example of how rating your client’s mood can be helpful. When I started working with Donald, his depression was at a 10 and we wondered whether he should be hospitalized. After about six months of therapy, Donald had significantly improved, and his moods were generally in the 4 to 5 range. He had been away and I had not seen him for over two weeks. He started his session saying he had been very depressed for the past two weeks, and he was scared that he would need to be hospitalized. He rated his overall mood at an 8. Realizing he was at an 8 and not a 10 helped him feel less frightened and enabled him to focus on the issues related to his increased depression. Bridge to the last session. This is an opportunity to follow up on any issues from the previous session, including asking about specific areas in your client’s life that you are worried about. For example, if I have a client who has been suicidal, during the check-in I ask about current suicidal thoughts and behavior. If a client is working on a specific issue, such as reducing weekend binge drinking or stopping cutting herself, even if the client doesn’t mention drinking or cutting, I will ask as part of the check-in. This provides a sense of continuity to the work of therapy. Review the homework. The check-in is a good time to review any homework, though some therapists review homework as part of setting the agenda. A large meta-analytic study (Mausbach, Moore, Roesch, Cardenas, & Patterson, 2010) found that homework completion was significantly related to a positive outcome in therapy. This means we need to do everything we can to encourage our clients to complete their homework. Asking about and reviewing homework tells your client that homework is important and encourages completion. If your client completed her homework, give positive feedback and indicate that it is important. Check what she actually did as well as the outcome. Clients don’t always understand the homework in the same way you intended it. You then want to ask what your client learned from doing the homework. If your client did not complete the homework, explore what got in the way. I usually ask my client what might help her complete homework in the future. If possible, we spend some time completing the homework task in session. At the end of the session, I spend extra time making sure the homework for the coming week makes sense to my client. Later in this chapter we are going to talk about how to develop effective homework. Identify possible agenda items. Issues raised in the check-in are often good issues to put on the agenda for the therapy session. For example, if a client tells you that she is thinking of breaking up with her boyfriend, or that she impulsively spent too much money on clothes again, you can say, “I want to check if this is something that you would like to talk about today” or, “Is this something that we should put on the agenda?” It is important to check, as sometimes when asked, clients realize that this is not really what they want to talk about. KEEP THE CHECK-IN FOCUSED The challenge with the check-in is to keep it short and focused. This means that rather than immediately exploring an issue your client brings up, you need to contain the client and make sure this is what she wants to address in the therapy session. For example, imagine that during the check-in your client starts giving a long and complicated example of a difficulty she is having with her child’s teacher, and you have not yet set the agenda. You might say, “I think this is an important topic. However, before we talk more about it, I want to make sure this is what you want to focus on today and see whether there are any other issues.” If you have explained to your client that she will set the agenda at the begin- ning of the session, she will find it normal that you stop and check what she wants to talk about. She may say, “Yes, this is the main issue.” In that case, you have your agenda. The check-in is a balance between exploring issues enough to have some understanding of the issue and make sure there is no immediate crisis, and not letting the check-in take the whole session. Here are some phrases that I have found helpful in keeping my client focused during the check-in: •That sounds like a really important issue. Before we talk more about it, I want to check if there is anything else that happened this week or anything else you want to bring up in therapy today. •That sounds pretty upsetting, and it would be important to talk more about it. Before we go into more detail, I want to be sure I get an overall sense of how you have been since our last session. •I can see how upsetting that would be. I want to write it down to be sure we get back to it, but I also want to check up on what we talked about last week. When a client comes in and starts talking about an important situation in her life, it can be hard not to get pulled into starting therapy and forget about finishing the check-in or setting an agenda. You can be straightforward and simply say, “I just realized that we started talking about this issue, and I never asked if this is the main topic you want to talk about today.” A word of caution: while CBT sessions follow a set structure, it is important to be flexible and sensitive to your client’s needs. For example, if a client starts a session by sobbing as she tells me about an awful event that just occurred, of course I would not rigidly keep to a structured session. I listen empathically, assess her immediate needs, and help her deal with her overwhelming emotions. However, after I have listened to what happened, if the client is calmer, I might say, “I want to talk more about this. But I also want to double-check whether there is anything else you want to talk about today.” I have often been surprised that even if my client is in the middle of a crisis, there may be additional issues she wants to address.

SUZANNE’S THERAPIST STARTS WITH A CHECK-IN Let’s look at an example of how a check-in might work. This is Suzanne’s fourth session and her therapist has already explained using a structured session. Before reading the dialogue below, ask your- self: how would you start the session? Therapist:Hello, good to see you. I would like to check in, see how your week has been, make a list of what you would like to focus on today, and hear how the homework went. Suzanne:(looking downcast) Well, my week has been pretty much the same and pretty awful. I did the homework and have it here. Suzanne’s therapist wants to follow up on the homework but also wants her to rate her mood and continue with the check-in. Therapist: It’s great that you did the homework; I want to follow up on it, but first I want to get an overall sense of your week and check what we need to focus on today. Is that okay with you? (Suzanne nods.) I was wondering…if you were to rate your mood over the past week, where would you put it? Note how the therapist redirects Suzanne to the tasks of the check-in. Suzanne:Probably overall a 7; I just felt really down a lot of the time. Therapist:So the same as last week. Were there any times that were particularly hard, or any times when your mood was better? Suzanne:I’m not sure, I was pretty down most of the week. Home is still the same. I can’t stand the new school. I think the teachers are really awful. No matter how hard I try, I just don’t fit in. (Sounding more upset and agitated.) One of the teachers asked me what I do at lunch, since she never sees me in the lunchroom. I didn’t know what to say. This could be a good issue to focus on in therapy as it relates to Suzanne’s goal of “trying to fit into the new school.” However, it is also not a crisis issue and other issues might be more important. Notice her therapist did not respond, “How did you feel when she asked you what you do at lunch?” or “Tell me more about that,” as these responses would encourage Suzanne to keep talking about that incident. Therapist:Sounds like you were pretty upset by the teacher’s comment. Before we talk more about it, I want to check if that was the main thing you wanted to talk about or whether there were other issues. Suzanne:That just happened this morning. I don’t really want to spend time on it; it’s not that important. At this point in the check-in, Suzanne has indicated that there have not been any changes in her life and she has rated her overall mood. There is nothing the therapist wants to raise as a bridge from the last session. The next step is to discuss the homework and set an agenda.

Your Turn! Help Raoul Stay Focused During the Check-In Let’s see how Raoul’s therapist uses the check-in. Therapist: Hello, good to see you. I would like to check in, see how your week has been, see what you would like to focus on today, and go over your homework. Raoul: (looking agitated) I’ve been really anxious all week. I have a major deadline on a project that’s due, and I am way behind. My boss must think I am a total loser. My anxiety is through the roof. I don’t know what’s the matter with me, I should just do the project. Look at the three possible responses below. Choose the response that will help Raoul stay focused on checking in.

I can see why you would be anxious. You have done really good work in the past. What makes you think that your boss thinks you are a loser?
Let’s see if we can help you with your deadline. What do you need to do to meet the deadline?
Sounds like it would be important for us to look at what is going on with the project. Before we do that, I want to check whether anything else happened this week that is important to you. Response #3 keeps Raoul focused on the check-in and structure of therapy. His therapist is also dem- onstrating empathy about the urgency of the project. In response #1, the therapist tries to be supportive but assumes that this issue with the boss is the main agenda item and has not checked in or set an agenda. In response #2, the therapist starts to problem solve without being sure this is the topic Raoul wants to focus on. Therapist Sounds like it would be important for us to look at what is going on with the project. Before we do that, I want to check whether anything else happened this week. Raoul: I’ve been so anxious, I haven’t been sleeping, but otherwise nothing is really new. In this situation you have an agenda item that came from the check-in. Before you start discussing the agenda item, you need to ask Raoul to rate his overall mood during the week, and check if there are any other issues he would like to talk about in therapy. All you need to say is, “Before we talk about your difficulties with the project, I want to do a quick check on how your overall mood has been this past week. How would you rate your mood, from 1 to 10?” Exercise 4.1: Eulela Has a Very Bad Week Practice keeping the check-in focused when the client has multiple problems.

Agenda Item #3: Collaboratively Set an Agenda Setting an agenda involves collaborating with your client to make a list of what she wants to focus on in the session. Some therapists think that setting an agenda sounds like a business meeting, but it is actually very client focused. When you set an agenda you are saying, “I care that our therapy focuses on what is important to you, so at the beginning of our session I want to spend a few minutes checking on what you want to talk about.” The process involves the client expressing her needs, and you, the therapist, hearing and responding to her needs. This can be very empowering for your client. Setting an agenda also sets the expectation that therapy is not just about coming and talking; you expect your client to work on specific problems and to give some thought to what she wants to talk about. You, the therapist, can also add issues to the agenda. For example, if you talked with a teenager’s probation officer or parent, this would be a good time to let the teen know and add it to the agenda. It is helpful to write out the agenda and place it where you and your client can both see it. Many thera- pists have a white board or flip chart in their office, but you can also use a piece of paper. Clear Agenda  Focused Therapy  Effective Therapy and Satisfied Clients One of the many things I like about setting agendas is that it helps with what I call “doorknob therapy.” Doorknob therapy is when you have finished the session and your client has a hand on the doorknob, ready to leave, and says, “Oh I forgot, I wanted to talk to you about this really important issue.” You can then say, “That sounds like an important issue. Can we put it on the agenda for next time, and start with it?” If your client regularly raises important issues at the end of therapy, you can start therapy by saying, “The last couple of sessions it wasn’t until the end that you remembered an important issue you wanted to talk about. I thought it might be helpful to take a moment and think about what you want to talk about today.” As your client learns to set an agenda for her therapy session, she is taking responsibility not only for her therapy, but also for making changes in her life. Once you have a list of agenda items, the next step is to ask the client which issue she would like to start with. If a client has a large number of issues on the agenda, I simply say, “There are too many issues for us to talk about all of them today. Let’s choose two or three and see if we can start to work on them.” It can also be helpful to decide roughly on the amount of time you will spend on each issue. At about the midpoint of the session I usually let my client know the time and ask whether she wants to stay on the issue we are discussing or move to the next issue on the agenda. Below are some helpful questions for setting an agenda. You can download a Questions to Help Set an Agenda handout at http://www.newharbinger.com/38501. •What would you like to focus on today? •What shall we put on the agenda for today? •Should we make a list of what you would like to talk about today, and then choose where you would like to start?

SUZANNE’S AGENDA Let’s look at how Suzanne’s therapist sets the agenda after they finished the check-in. If you remem- ber, in Suzanne’s case there were no agenda items that came from the check-in. Therapist:I want to spend a few minutes making a list of what you would like to focus on today. I also want to be sure we spend some time going over the homework, but I want to check whether there is anything else you want to bring up. Suzanne:Actually, the main issue I want to talk about is that I got an invitation from the principal to a barbecue for new teachers at his home. I’m really anxious, and not sure if I should go. Therapist:That sounds like an important issue. Anything else you want to talk about? Suzanne:Actually, yes, I have been really angry with my husband this past week. He promised to take care of the kids on the weekend and ended up working. Those are the two big ones I want to talk about. Both issues relate to Suzanne’s goals. It is just a question of which is more important to her. Therapist:Between the barbecue and being angry with your husband, where would you like to start? Suzanne:I think the barbecue, as I’ve been really worried about it. The issue with my husband doesn’t feel as urgent. Therapist:Would it be okay if we start with looking at the homework, then spend some time talking about the invitation to the barbecue, and if we have time, finish with looking at how angry you have been with your husband? Suzanne:That sounds good. RAOUL’S AGENDA Raoul had identified an agenda item in the check-in. His therapist wants to check whether there are additional issues he wants to talk about in session. Therapist:I would like to make a list of what we want to focus on today. One issue that you identified is the project that is due; is there anything else you would like to talk about today? Raoul:Actually, my wife wants to invite her sister to stay with us for a month while she looks for a new job. I’m really upset—what if it takes her sister a really long time to find a job? We can’t just let her move in, but we can’t say no, she’s family. Her sister is a very difficult woman who talks all the time. She expects us to just take care of her. Therapist:Sounds like it would be important to talk about your wife’s sister maybe moving in, too. I just want to check if there is anything else. Notice how the therapist summarizes the problem to indicate she heard Raoul’s concern, but then sticks to setting the agenda. Raoul: Those are the two. I have to say, the idea of my sister-in-law living with us is not great. She’s pretty critical, and I don’t think she really likes me. She also puts my wife down all the time. It is tempting to start talking about the sister-in-law; however, we have not asked Raoul where he would like to start. Therapist:We have two big issues; which one would you like to start with, the project at work or your sister-in-law? Raoul:I think the project, because if I don’t get this project done, I risk another bad work evalu- ation! It’s just all so much. Therapist:It is a lot. How about if we started with the project? I’ll let you know when we are halfway through the session and then we can talk about your sister-in-law. Notice how the therapist sticks to the structure but adds the empathic comment “It is a lot” to indicate that she heard Raoul’s distress. Agenda Item #4: Work the Agenda Once you have set an agenda and decided on the first item, the next step is to start working on that issue in therapy. One of the challenges is sticking to an agenda item. In my experience, therapy drifts. For example, a client may start talking about her anger toward her father, who criticized her parenting, and drift to talking about her feelings toward her cousin who is moving away. It is easy to stray from the agenda. When you talk with a friend, you drift from topic to topic; however, in therapy you want to focus on a specific problem. The easiest way to keep your client focused is to point out that she has strayed from the agenda and ask her what she would like to do. You can gently say, “We were talking about your feelings toward your father, and we’ve moved to talking about your cousin. I am wondering if you want to go back to discuss- ing your father, or if this issue with your cousin is more important.” That way, you give your client a choice. However, it is important to be flexible. If your client starts to talk about a painful issue that has been difficult for her to discuss or discloses a traumatic or very distressing event, you follow your client’s lead. Exercise 4.2: Dewei Uses Marijuana Again Practice keeping to a structured session. Video 4.1: Check In and Set an Agenda

Agenda Item #5: Develop Helpful Homework for the Next Session Homework is an opportunity for your client to practice in her everyday life what she worked on in therapy. In a meta-analytic study, Kazantzis, Whittington, and Dattilio (2010) found that overall, 62 percent of clients improved when therapy included homework, compared with 38 percent of clients who improved when therapy did not include homework. This seems to me like a pretty compelling reason to include homework in your therapy. Homework can take many forms. Some examples might be noticing the situations where your client has specific difficulties, asking your client to complete a thought record, or asking your client to try a new behavior. Clients who complete homework tend to benefit more from therapy (Rees et al., 2005). So, how do you increase the chances that your client will complete her homework? First, be sure to leave between five and ten minutes at the end of the session to plan the homework. Assignments given in a rushed manner tend not to get done. Second, use the following four criteria to develop helpful homework. You can download a Guidelines for Helpful Homework handout at http://www.newharbinger.com/38501. •Developed collaboratively with your client •Specific and concrete •Related to the session •Doable Developed collaboratively. Ideally, the homework comes out of a discussion with your client. I often start with asking, “What do you think would be a good way to practice what we have talked about today during the coming week?” While your client may have some good suggestions, frequently it is the therapist who suggests specific homework. It is important to check your client’s reaction to any home- work that you suggest. I usually say, “One idea I had was for you to… What do you think?” My clients often have good ideas about how to modify my suggestions. Specific and concrete. You and your client need to be clear on what she is going to do for homework. To decide if the homework is specific and concrete, ask yourself: Is there a specific behavior my client is going to try? How often will my client do the homework? Where and when will my client do the homework? For example, “Try to notice your negative thoughts” is not very specific or concrete. A more specific assignment would be, “When you get angry at your teacher in science class, write down the thoughts that go through your mind. Do you think you can do this twice this coming week?” Your client then knows what she will do, in what situation, and how often. Unless homework is specific and concrete, it is impossible for your client to accurately evaluate whether she completed the homework. For example, Raoul’s homework was to start work on a group project he had been avoiding. The next session Raoul reported that he contacted his colleagues and set up a meeting for next Tuesday. Raoul added, “I wasn’t able to do the homework; I should have already started the project.” If his homework had been to contact his colleagues and set up a meeting, might Raoul have had a different reaction?

It is important to start developing the homework when you have at least five minutes left in the session. Notice that the therapist first asks Suzanne whether she has any ideas. Suzanne: No, not really. Therapist: I am wondering if you could think of one activity that you used to do with your children that you would like to start doing again this week. If Suzanne could think of an activity, together they would make a specific plan that included when the activity could happen and specifically what Suzanne would do. The therapist would check that the plan felt doable and that Suzanne had everything she needed to do the homework. Lastly, the therapist would check if there were any obstacles. Suzanne and her therapist decided she would sit with her children for ten minutes on the couch and watch TV with them before starting dinner. Suzanne would do this Monday and Wednesday evening this coming week. Is this homework collaborative, specific and concrete, related to the session, and doable? I think it is. I don’t want my client to think that she failed if she does not do the homework or it does not go well. I often end our discussion about homework by saying, “If you do the homework, that is great and it will help us see how you can start moving toward your goals. If you don’t do the homework, it is important that we explore what happened, as this will give us some clues as to what is keeping you stuck in your problems.” Renee Tries to Catch Up at School, and (b) Wilson Feels: (a)Tense Exercise 4.3 Practice using the homework guidelines. Agenda Item #6: Review the Session and Ask for Feedback The last section of a structured session involves reviewing the session and asking for feedback. This section is often forgotten or rushed, but it is just as important as the other components. REVIEW THE SESSION One of the best ways to help your clients remember what was covered in therapy is to ask them to review. If they forgot to mention a point you think was important, you can raise it and ask if it also seems important to your client. Many of my clients keep notebooks and either during the session or at the end write down the points they want to remember. In my clinical notes, I also write down the main points from the review. Below are some helpful ways to introduce reviewing the therapy session. You can download a Questions to Review the Therapy Session handout at http://www.newharbinger .com/38501. •Before we end, let’s take a moment to review. What was most important to you from our session today? •Before our session is up, let’s take a moment to think over what we talked about today. I think we talked about some very important things, and I want to be sure that we don’t forget them. Could you write down anything you would like to remember? •I was thinking it would be helpful to stop and just summarize what we talked about. How could you put what we talked about into your own words? A few years ago I noticed that if I thought the session had not gone well, I would “forget” to review, or else I conveniently ran out of time. When I started reviewing even when I thought the session had not gone well, I discovered that a good part of the time my client had found the session helpful. This was very useful information. If my client had not found the session helpful, this was also valuable infor- mation. We now had a problem we could discuss and potentially solve rather than my worrying about the session. ASK YOUR CLIENT FOR FEEDBACK After you review the session, it is a good time to ask for feedback. This is especially important in the beginning of the therapy relationship. I simply say, “I want to check if it feels that we are on the right track” or “I want to check if there was anything that we did that was particularly helpful for you. Was there anything that didn’t feel like a helpful use of our time?” Your Turn! Practice in Your Imagination: Review a Session with Your Client  Choose a client you are currently seeing who you think would be open to reviewing the session. Before we begin, rate from 1 to 10 how comfortable you are with asking your client to review the session, with 1 being very comfortable and 10 being very uncomfortable. At the end of the exercise, rate your level of comfort again to see whether it has changed. Now, let’s try the exercise. Imagine you are at the end of a session and you want to ask your client to review the session. Try to get a picture of him or her in your mind. Imagine yourself in your office. Take a moment to look around, notice the sounds and smells in the room. Read over Questions to Review the Therapy Session while imagining yourself asking the questions. You can also use your own phrases. Really hear and feel yourself introducing the idea of reviewing. Now imagine review- ing two more times with the same client. Each time imagine that your client responds positively. Video 4.2: Review and Ask for Feedback on the Session

Homework: Practice CBT Before continuing with the next chapter, take some time to try the homework. Apply What You Learned to Clinical Examples Complete the following exercises. Exercise 4.1: Eulela Has a Very Bad Week  Exercise 4.2: Dewei Uses Marijuana Again Exercise 4.3: (a) Renee Tries to Catch Up at School, and (b) Wilson Feels Tense Apply What You Learned to Your Own Life Most of us wake up every morning and there is a long list of what we have to do. We have to priori- tize and figure out what is most important to us, or we would never get anything done. Setting agendas in therapy is similar to figuring out what is most important to attend to in our own lives. Homework Assignment #1 Use a Structure in Your Life An agenda is a list to help your clients identify and prioritize what is most important to them. Many people make lists to help them organize their lives and figure out what needs to be done first. I thought it would be helpful for you to reflect on your own experience of making lists and identifying your priorities. First, consider lists you’ve written in your life. Take a moment and think about a time when it was helpful to make a list, and a time when it was not helpful. Then identify factors that contributed to the list being helpful and factors that contributed to the list not being helpful. Second, think about the next couple of days. Make a list of things you need to accomplish in the next few days that are not part of your normal routine. It can be either at work or in your personal life. After you’ve made the list, pick three items that are a priority to accomplish. Try to make them as concrete and specific as possible. Third, think about this exercise and if there are any implications for how you can make agenda setting more helpful for your clients. Now take a moment to review what you learned. Apply What You Learned to Your Therapy Practice I want to explore your expectations and any concerns you have about using a structured format.

Homework Assignment #2 Explore Your Attitudes about Using a Structured Format Choose two clients whom you are currently working with. Imagine that with each client you set an agenda and review at the end of the session. I am going to ask you to write down your predictions. Complete the following form for each client.

My client will: 1 2 Dislike using a structure 3 4 Have a neutral reaction 5 Like using a structure
I will: 1 2 Dislike using a structure

3 4 Have a neutral reaction 5 Like using a structure What I imagined happening: 4. My main concern about using a structured format with this client is: Homework Assignment #3 Structure a Session with a New and Current Client Choose two clients with whom you are going to try and structure a session. If possible, choose one new client and one current client with whom you are not using a structured session. You are more likely to learn a new skill if you practice the different components individually before you put it all together. I want you to start by only practicing three components of a structured session: (1) explain the structure of a therapy session, (2) set an agenda, and (3) choose an agenda item to focus on. Here are the three steps:

Explain the structure of a therapy session: Explain to your client that you would like to make a list of what she wants to talk about. You can look back through this chapter to see how to introduce setting a structure with new and current clients. Remember that to set an agenda all you have to do is say, “I would like to make a list of what you would like to talk about today.” If it is the first time you are trying to set an agenda, you may find it helpful to have a copy of the handout Explain the Structure of a Therapy Session beside you. Set an agenda: Once you and your client have set the agenda and identified the issues he or she would like to focus on, write them down where you can both see them. Choose an agenda item: Once you have your list of agenda items, ask your client which item he or she would like to start with. If you are setting an agenda with a current client, at the end of the session ask if your client liked setting an agenda. You can say, “I am curious whether you liked the structure we used today where we made a list of what you wanted to work on.” If your client had a positive reaction, ask if she would like to continue using this structure in the future. After you try setting an agenda for the first time, notice if your predictions about your own and your client’s reactions were accurate. Take a moment to think about what you learned. Have your pre- dictions changed? Homework Assignment #4 Review the Session with Your Client Once you have tried setting an agenda with two clients, I would like you to include one more compo- nent of a structured session. At the end of the session, ask your client to review the session. Remember, all you have to do is ask, “When you look over our work today, what would you like to remember?” As you did in the last exer- cise, notice if your predictions of your own and your client’s reactions were accurate. Let’s Review Answer the questions under the agenda items. Agenda Item #1: Organize your therapy sessions. •What are the main components of a structured therapy session? •What is the importance of each component?

Agenda Item #2: Start with a check-in. • What is included in a check-in? Agenda Item #3: Collaboratively set an agenda. •How could you introduce setting an agenda with a new client? •How could you introduce setting an agenda with a current client? Agenda Item #4: Work the agenda. • How could you respond when your client drifts off the agenda topic? Agenda Item #5: Develop helpful homework for the next session. • What are two guidelines for helpful homework? Agenda Item #6: Review the session and ask for feedback. • How could you ask your client to review? What Was Important to You? What idea(s) or concept(s) would you like to remember? What idea(s) or skill(s) would you like to apply to your own life? What would you like to try this coming week with a client? (Choose a specific client.)