CBT Session Structure and Use of Homework
Importance of Time Management
The importance of promoting resilience and avoiding dependence makes it vital to manage time well, in terms of both individual sessions and the course of sessions as a whole. For example, many agencies that provide CBT may offer a limited number of sessions (perhaps from six to 12).
This means that careful planning is required to ensure that the client is clinically safe to leave at the end of each session and – in particular – at the end of the full course of sessions.
Having limited time can be used in a positive way to focus the client on working hard to collaborate with the therapist and to explore their own thoughts, feelings and behaviours. It is ethically appropriate to explain to the client that CBT is a gradual process that will help them take incremental steps towards changing their thoughts, emotions and behaviours.
Session Agenda
Structure is one of Bordin’s (1979) triad of elements of CBT. As well as the idiosyncratic formulation – often seen as the ‘backbone’ of CBT treatment, and displayed between therapist and client (e.g. on a table where each can see it clearly) during sessions – another key tool in structuring CBT is the session agenda.
The session agenda is agreed collaboratively at the start of each session, based on items that the therapist and client wish to include. It is helpful to relate the structure of each session to the formulation. This also has a role in supporting the client’s education in the CBT model. Key items would typically be:
- following up homework completed since the previous session
- briefly reviewing the client’s experience since then
- practising CBT tasks.
As the BABCP emphasises, it is vital in CBT that the therapist and client work together in changing the client’s behaviours, thinking patterns or both. Because the active involvement of the client is required, it is important to set and work to an agenda, so setting out clearly the expectations of the client at every stage, making use of limited time and giving the sessions a problem-solving atmosphere.
The therapist has a responsibility to ensure that the agenda is of a manageable size, reining in client expectation if need be so that it can be achieved within the 50-minute session. As with the formulation, it is useful for both parties to be able to see the agenda during the session.
Agenda-setting also serves to strengthen the working alliance. Simmons & Griffiths (2014: 39) observe: ‘Setting the agenda together with your client underlies the general philosophy of CBT, that of active collaboration between therapist and client.’ Indeed, the therapist may even include time to obtain client feedback on the working alliance at the end of each session (by adding ‘Feedback’ to the agenda).
Use of ‘Homework’
A common feature of CBT is that the therapist sets the client ‘homework’, which is then reviewed in the next session; this aims to help clients generalise and apply their learning.
Homework in CBT refers essentially to tasks set to be completed by the client between sessions. For some clients, ‘homework’ is a word that triggers difficult memories of school days, possibly for some linked to a failure or other schema. It is therefore important to be aware of any such sensitivity in clients.
For example, if a client’s failure schema is triggered by the term ‘homework’, we might choose either to refer to it instead as ‘between-session tasks’ or to look with the client at how our use of the word is different from the way teachers used it at school – e.g. that CBT homework is always agreed (i.e. set collaboratively rather than imposed), and is about exploration and learning rather than any externally imposed expectation of outcome.
Purpose of Homework
Homework tasks are an important part of CBT practice, based on the view that client change does not come about purely as a result of in-session work – i.e. that significant effort is required by the client between sessions. In other words, there are 168 hours in the client’s week and only one of them is spent with the therapist.
Introducing the concept of homework early in therapy is also useful in getting the message across to the client that the working alliance requires significant effort and commitment from them – i.e. in promoting the understanding that the responsibility for change lies very much with them, guided by the therapist as professional facilitator.
Homework can also help enhance client autonomy, showing them they can become their own therapist using the CBT model.
Tailoring Homework to Client Needs
Homework tasks should be tailored to the client’s idiosyncratic formulation. Key points to consider are how challenging it will be for the individual client – and also how specific, practical and measurable.
When negotiating homework, we must therefore always use the core conditions and put ourselves in the client’s frame of reference. For example, we might see a small change in activity levels as perfectly manageable but this may seem huge for a depressed client.
Homework tasks should be just enough to challenge a client to extend themselves but not so much that it feels overwhelming. In the latter case, the likelihood is that the client will then simply not attempt it at all, so negating the point of the homework entirely.
It is also important to bear in mind the client’s schemas when setting homework. For example, a client with a failure schema would need very manageable tasks in the early days (with less challenge built in), while a client with a subjugation schema might agree to homework they knew to be unsuitable just to please the therapist.
Checking Homework
It is important that the therapist remembers to check homework during the next session – otherwise, the client may feel frustrated that they have invested time and energy in doing this with no apparent interest or follow-up from their counsellor.
This could detrimentally affect the bond and also lead to non-compliance with homework tasks in future. Sufficient time should be allowed in the session agenda to discuss the client’s experience of their homework tasks and learning from these.
Again, the therapist should hold in mind when evaluating homework any client schemas that may affect this. For example, a client with an unrelenting standards schema might be harsh on themselves in evaluating their achievements.
In this case, the therapist would need to tease out the client’s successes, and could use the work to help challenge the related negative automatic thoughts (e.g. filtering, all-or-nothing thinking or discounting the positive).
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CBT Session Structure and Use of Homework
Non-Compliance with Homework
There are many possible reasons for non-compliance with homework tasks, and exploring these is an important part of therapy. Homework non-compliance may link with schema avoidance.
For example, a client may use avoidance to protect themselves from the difficult feelings associated with a failure schema. In other words, they may think that if they don’t attempt the homework task, then at least they can’t fail at it.
Offering the client the core conditions is important in exploring the reasons for non-completion of homework tasks. Clients may initially say they have not had time, and the therapist needs to take the time to discuss their real reasons for not doing the homework. This provides a valuable opportunity for new learning about – and hence understanding of – the client’s patterns of thinking, feeling and behaving.
References
Bordin E (1979) ‘The generalizability of the psychoanalytic concept of the working alliance’, Psychotherapy: Theory, Research and Practice, 16, 252–260.
Simmons J & Griffiths R (2014) CBT for Beginners, Sage