Time-Limited Treatment

Because cognitive therapy is focused on the resolution of specific problems and issues, it is by definition a time-limited treatment. The cognitive therapist is trying to “put himself or herself out of business” as quickly as possible with each patient. Protocols exist for a number of disorders, and the protocols often limit the number of recommended sessions. Even when a specific recommendation does not exist regarding the length of treatment, there is a sense that treatment should be focused and goal-oriented. These ideas can be communicated to the patient in the following ways: predictions by the therapist about the needed length of therapy, regular reviews of treatment progress, conscious efforts to transfer learning to the patient so that he or she can manage on his or her own, statements by the therapist about the pending end of treatment, and reviews of treatment process and outcomes. Even in cases where the problems are more amorphous, the therapist will discuss with the patient at intervals how treatment is going, what goal or goals are being served, and how much longer treatment might last.

Structured Therapy

Although the amount of structure in cognitive therapy can be overemphasized, as the approach is flexible in terms of how it is conducted, cognitive therapy does tend to be more structured than other forms of psychotherapy. This structure can be observed both within the context of any given session and across treatment sessions.

Intrasession Structure

Three distinct phases can be observed within each session of cognitive therapy. These phases can be conceptualized as a preparation phase, the “work,” and a completion phase. In the preparation phase, the therapist and patient greet each other and may engage in some small talk as they get settled. If the patient has completed any questionnaires or measures between sessions, the therapist will review them and might summarize their results. The therapist will inquire about events since the previous session and ascertain whether anything extraordinary has occurred that might require attention in the current session. If there has been a particular focus of therapy, there will often be a quick check-in about that issue. For example, if the focus has been on worry, the therapist might ask how much of a problem worry has been in the interval since the prior session. There might also be a “mood check” in the form of a rating from 0 to 100 if the focus of treatment has been on the reduction of a particular negative emotion.

The cognitive therapist will always inquire whether the patient was able to complete any assignment that was set during the previous session. If so, the results of the assignment will be quickly ascertained. If the homework was not attempted or if the patient had a significant problem with its completion, time will be set aside to determine what that problem was and how the assignment might be reattempted. Toward the end of the preparatory phase, the therapist will ask the patient whether he or she wants to focus on any particular issues in the current session. The therapist may add a topic if there is a particular technique or method that he or she wants to introduce or to develop. Together, the therapist and patient consider the range of items they want to include on a final agenda, prioritize them to ensure that the most important topics are addressed first and in the most detail, and perhaps assign time limits to some or all of the items to ensure that all the issues are adequately discussed. The entire preparatory phase takes at most 10 minutes, but more typically only about 5 minutes once the important topics have been established and the therapist and patient are meeting regularly.

After the agenda has been set, the topics are addressed. This work phase of therapy is the most diverse in form, as the nature of what is discussed and the methods that are used will vary dramatically across patients, problems, and phases of therapy. In general, this is the phase of the session wherein the therapist and patient together name and solve the patient’s problems by using a range of interventions. As described more fully below, at the conclusion of a topic discussion, an assignment or homework is often developed as a way to enact a concrete change in the patient’s life. The therapist keeps general track of the time and ensures that all of the important topics receive the attention they need in the session.

After each topic on the agenda has been discussed, the therapist will usually note that the therapy session is coming to an end. He or she will often invite the patient to summarize the session or to identify what he or she considers the most important things discussed. For example, the therapist might ask, “What are the most important things that you will take away from today’s appointment?” The response will help the therapist learn what the patient has attended to and will allow for either correction with regard to certain issues or a focus on other issues that the therapist wants to bring to the patient’s attention.

The ending part of the session also involves a review of the homework assignments that were developed over the course of the therapy session. The review may entail writing all of the homework down on an agenda form or in a notebook. It might also involve an adjustment of the homework, since there may be too little homework or too much to reasonably accomplish before the next session. The therapist often will ask for overall feedback about the session to ensure that the patient feels that his or her concerns were addressed and that the relationship is an effective one. The therapist might comment about the progress of therapy or briefly discuss some particularly successful or difficult aspects of the session. Finally, the date and time of the next session are set, payment is made (if relevant), and the patient leaves.