As for pacing, Dr. Sudak advised thinking of CBT as a learning model; if too much material is given too quickly it won’t be absorbed.
Session notes help focus time
The use of therapy notes can help with maintaining the focus on session goals. Providing and requesting feedback also can help keep the session on target, and can provide a summary with take-home points.
Handouts and homework assignments are important for brief CBT sessions, and should be readily available; in the brief session setting, there is little time for searching and downloading. Keep handouts and/or an Internet resource list readily accessible. It might be helpful to have a library of handouts or self-help materials set up in your office, Dr. Sudak noted.
Homework assignments such as thought records and activity schedules can be useful but should be developed collaboratively and rehearsed in advance to allow for troubleshooting when obstacles arise. Always be sure to follow up on assignments from the last session, Dr. Sudak said.
Difficulties with homework completion occur and should be normalized. When such difficulties occur, the assignments should be evaluated to determine whether they were appropriate and relevant to the session or problem, and it should be determined whether the patient was adequately prepared. Starting or completing assignments during the session can help, and it is important to check for negative thoughts about the homework, and to identify barriers and find solutions, she said.
"When the homework doesn’t go so well, part of what we have to do is not give up on it. One of the things that happens a lot, I think ... is that it’s easier to jettison that plan than to figure out why it didn’t work," Dr. Sudak said.
Figuring out what the barriers are can be a learning experience for both patient and therapist.
Brief CBT sessions have a great deal of potential for helping many patients, but in Dr. Sudak’s and Dr. Wright’s experiences, brief CBT sessions should be avoided in:
• Those with a diagnosis and complexity that suggest a need for full-course, standard CBT. They might include patients with personality disorders, history of trauma, family conflict, resistant depression, or acute crisis.
• Patients in whom brief CBT sessions have been tried but did not appear to meet their needs.
Dr. Sudak and Dr. Wright are two of four coauthors of the book "High-Yield Cognitive-Behavior Therapy for Brief Sessions: An Illustrated Guide" (Washington: American Psychiatric Association, 2010). They receive book royalties from American Psychiatric Publishing; Lippincott Williams & Wilkins; and John Wiley & Sons. Dr. Sudak is also on the editorial board of, and receives honoraria from, Elsevier, and is a consultant for Takeda Pharmaceuticals. Dr. Wright also receives royalties for the development of software (Empower Interactive, Mindstreet).