Intersession Structure

Just as there is a structure within sessions, there is often a structure to cognitive therapy across sessions. There may be a movement from a behavioral focus and a restoration of adaptive functioning to a focus on negative automatic thoughts and potential cognitive distortions and eventually to an examination and possible modification of underlying beliefs and schemas. The exact content of the work will vary from case to case, as different general conceptualizations guide the treatment of different disorders for different patients. Also, cognitive therapists are willing to backtrack and address an issue that was dealt with earlier in the course of therapy if it resurfaces or requires further attention.

Although there is considerable structure to the practice of cognitive therapy, the above ideas are general guideposts rather than rigid rules. Cognitive therapy is a flexible system of treatment, and therapists will sometimes modify the structure to respond to clinical exigencies. For example, if the patient divulges suicidal intent halfway through a session, the therapist will often postpone the work that is under way while a suicide assessment and intervention are conducted. A cognitive therapist might consciously set a single topic for a session’s agenda, if that topic is of critical importance at a given stage of therapy, although cognitive therapy sessions typically involve two to four topics in the work phase. If a patient is particularly distraught or having difficulties with concentration, the therapist might purposely shorten the session with the knowledge that although less will be covered, what is covered is likely to be remembered and acted upon.

Key Roles of Activity and Homework

As discussed in Chapter 3, cognitive therapy is one of the cognitive–behavioral therapies. In this context, it should not be a surprise to learn that cognitive therapists assess and promote both cognitive and behavioral change in the service of overall better adaptation and functioning. Indeed, consistent with the realist aspect of the cognitive model, cognitive therapists are conscious of the need to translate whatever is discussed in the therapy session into concrete action. One could even argue that what goes on between therapy sessions could be considered more important that what goes on within each session.

Because of the perceived importance of real-world change in cognitive therapy, cognitive therapists often use homework activities. Such homework is highly variable in its content, as it varies from case to case, within cases over time, and across different problems. In some cases, homework is used to gather new information about how the patient functions in his or her social environment. In others, it might be used to gather evidence to assess the validity of certain negative thoughts. Homework might serve to elicit new thoughts, which can then be examined and discussed in the coming treatment sessions. The therapist and patient may agree to homework that promotes schema change.

The idea of homework carries some unfortunate connotations. The first is that of school and that homework in cognitive therapy is merely an educational activity. Such an inference is not correct, since homework in cognitive therapy could be just as easily called a task, a mission, a challenge, an experiment, or an assignment. Indeed, if school has a negative association for the patient, the word homework might best be avoided.

The second possible connotation is that homework is simply educative. Again, this inference is erroneous. Homework is often educative, but it can also be investigative, confrontational, or experiential. In addition, homework can be directed toward thoughts or behavioral change. It can also be directed to changes in relationships, emotional experiences, and even physiology (e.g., diet changes, medication changes). The term is in some ways a catchall for any translation of therapy discussion into a concrete change in the way that the patient relates to his or her world.

Homework is always used in good cognitive therapy (Kazantzis & Deane, 1999; Kazantzis, Deane, Ronan, & L’Abate, 2005). The cognitive therapist is constantly on the lookout for methods to create lasting change in the patient’s problems and will stay mindful of possible homework assignments. As the focus of a therapy session moves from one area to another, the therapist will summarize what has been discussed (or have the patient provide a summary) and will ask about a possible homework assignment. Early in the course of therapy, the therapist may propose assignments, but as therapy progresses and the patient learns about assignments, the therapist will often transfer the task of setting assignments to the patient. Ideally, both the therapist and patient will concur about the importance of any given assignment, and both will leave the therapy session with a clear idea of what the homework is, when it will be conducted, and what the potential outcomes are.