CBT: Making the most of a brief session

SAN ANTONIO – Cognitive-behavioral therapy, or CBT, can be effectively used during brief sessions in certain cases.

For example, brief CBT sessions can be useful in patients with Axis I disorders for which pharmacotherapy is being used effectively, and in patients in whom symptom complexity does not appear to require longer sessions, Dr. Donna M. Sudak and Dr. Jesse H. Wright said during a premeeting workshop at the annual meeting of the American College of Psychiatrists.

Other patients for whom brief CBT sessions might be indicated include inpatients; those with a preference for shorter sessions; those on long-term pharmacotherapy; and those with illnesses for which brief treatment may be advantageous, including psychosis, bipolar disorder, obsessive-compulsive disorder, uncomplicated anxiety disorders, and substance abuse requiring frequent visits, according to Dr. Sudak, professor and director of the psychotherapy training program at Drexel University, Philadelphia, and Dr. Wright, professor and director of the Depression Center at the University of Louisville (Ky.).

The format for providing brief CBT sessions can vary. For some patients, an initial evaluation followed by brief sessions might be appropriate. Other patients might be best served with several 50-minute sessions, followed by a transition to brief sessions later in treatment. Some patients might require a mixture of 50-minute and brief sessions, and some might do well with a team approach in which a psychiatrist provides brief sessions and a nonphysician CBT-trained therapist provides longer sessions or a nonphysician therapist provides therapy from a different orientation.

The selected format should be based on the patient’s need and preference, and can change over time, Dr. Wright said, noting that many patients prefer brief sessions because of time constraints.

Numerous high-yield interventions can be used in brief CBT sessions. Some examples include adherence enhancement; behavioral activation, which is particularly potent for treating depression; breathing retraining; CBT for insomnia, which is an area of increasing interest; cognitive-behavioral rehearsal; collaborative empiricism; collaborative goal setting; computer-assisted CBT; eliciting of and modification of automatic thoughts; exposure; cognitive error identification; motivational interviewing; psychoeducation; and relapse prevention.

Dr. Sudak and Dr. Wright shared several strategies aimed at enhancing the effect of brief CBT sessions.

Improving each session

First, make certain to have a clear formulation of the patient, they said.

Key elements of the formulation include diagnosis and symptoms; formative influences; situational issues and biological factors; strengths and assets; cross-sectional and longitudinal formulation; and a working hypothesis and treatment plan that is developed based on how all of these factors "pull together to influence the way this person thinks about the world, and [her] skill set in terms of working with other people and managing [her] own emotions."

Miniformulations developed during the course of care also can be helpful. These formulations address a specific issue that needs to be addressed "right now." Such formulations are collaboratively developed, simple and easily understood, and provide targeted direction for therapy interventions.

Dr. Sudak said she will sometimes draw a miniformulation on a whiteboard during a session, and will have the patient draw the same on a piece of paper to take home. She gave an example involving a "feedback loop" in a patient who hears teenage girls laughing while he is walking to the store. He experiences the thought that they are laughing at him, and that they therefore must think he is "a loser." This causes feelings of fear and sadness, leading him to keep his eyes down and return home without going to the store.

The miniformulation in this case involved drawing a circular graphic to outline the feedback loop and work on strategies for developing more realistic, healthier thoughts about being out in public, and for working on becoming more comfortable around other people, gradually increasing the ability to be in public settings.

A specific treatment plan should be developed for each session based on these formulations.

Techniques used in the course of treatment should include those that are most likely to be effective in briefer formats. Particularly high-yield techniques for brief CBT sessions include adherence enhancement, behavioral activation, and thought change records.

Also, special attention should be paid to the relationship and to pacing.

Enhancing the therapeutic relationship is important regardless of session length, but is particularly important for brief sessions, Dr. Wright said.

Helpful techniques for relationship building include emphasizing a team approach with shared responsibility; staying tuned to the patient’s emotion – and responding with accurate empathy; giving the patient your full attention and avoiding digressions; choosing targets for change with high relevance and opportunities for success; and building communication skills. In addition, listening carefully, giving clear explanations, summarizing key points, and asking for and giving feedback help build relationships.

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).

SAN ANTONIO – Cognitive-behavioral therapy, or CBT, can be effectively used during brief sessions in certain cases.

For example, brief CBT sessions can be useful in patients with Axis I disorders for which pharmacotherapy is being used effectively, and in patients in whom symptom complexity does not appear to require longer sessions, Dr. Donna M. Sudak and Dr. Jesse H. Wright said during a premeeting workshop at the annual meeting of the American College of Psychiatrists.

Other patients for whom brief CBT sessions might be indicated include inpatients; those with a preference for shorter sessions; those on long-term pharmacotherapy; and those with illnesses for which brief treatment may be advantageous, including psychosis, bipolar disorder, obsessive-compulsive disorder, uncomplicated anxiety disorders, and substance abuse requiring frequent visits, according to Dr. Sudak, professor and director of the psychotherapy training program at Drexel University, Philadelphia, and Dr. Wright, professor and director of the Depression Center at the University of Louisville (Ky.).

The format for providing brief CBT sessions can vary. For some patients, an initial evaluation followed by brief sessions might be appropriate. Other patients might be best served with several 50-minute sessions, followed by a transition to brief sessions later in treatment. Some patients might require a mixture of 50-minute and brief sessions, and some might do well with a team approach in which a psychiatrist provides brief sessions and a nonphysician CBT-trained therapist provides longer sessions or a nonphysician therapist provides therapy from a different orientation.

The selected format should be based on the patient’s need and preference, and can change over time, Dr. Wright said, noting that many patients prefer brief sessions because of time constraints.

Numerous high-yield interventions can be used in brief CBT sessions. Some examples include adherence enhancement; behavioral activation, which is particularly potent for treating depression; breathing retraining; CBT for insomnia, which is an area of increasing interest; cognitive-behavioral rehearsal; collaborative empiricism; collaborative goal setting; computer-assisted CBT; eliciting of and modification of automatic thoughts; exposure; cognitive error identification; motivational interviewing; psychoeducation; and relapse prevention.

Dr. Sudak and Dr. Wright shared several strategies aimed at enhancing the effect of brief CBT sessions.

Improving each session

First, make certain to have a clear formulation of the patient, they said.

Key elements of the formulation include diagnosis and symptoms; formative influences; situational issues and biological factors; strengths and assets; cross-sectional and longitudinal formulation; and a working hypothesis and treatment plan that is developed based on how all of these factors "pull together to influence the way this person thinks about the world, and [her] skill set in terms of working with other people and managing [her] own emotions."

Miniformulations developed during the course of care also can be helpful. These formulations address a specific issue that needs to be addressed "right now." Such formulations are collaboratively developed, simple and easily understood, and provide targeted direction for therapy interventions.

Dr. Sudak said she will sometimes draw a miniformulation on a whiteboard during a session, and will have the patient draw the same on a piece of paper to take home. She gave an example involving a "feedback loop" in a patient who hears teenage girls laughing while he is walking to the store. He experiences the thought that they are laughing at him, and that they therefore must think he is "a loser." This causes feelings of fear and sadness, leading him to keep his eyes down and return home without going to the store.

The miniformulation in this case involved drawing a circular graphic to outline the feedback loop and work on strategies for developing more realistic, healthier thoughts about being out in public, and for working on becoming more comfortable around other people, gradually increasing the ability to be in public settings.

A specific treatment plan should be developed for each session based on these formulations.

Techniques used in the course of treatment should include those that are most likely to be effective in briefer formats. Particularly high-yield techniques for brief CBT sessions include adherence enhancement, behavioral activation, and thought change records.

Also, special attention should be paid to the relationship and to pacing.

Enhancing the therapeutic relationship is important regardless of session length, but is particularly important for brief sessions, Dr. Wright said.

Helpful techniques for relationship building include emphasizing a team approach with shared responsibility; staying tuned to the patient’s emotion – and responding with accurate empathy; giving the patient your full attention and avoiding digressions; choosing targets for change with high relevance and opportunities for success; and building communication skills. In addition, listening carefully, giving clear explanations, summarizing key points, and asking for and giving feedback help build relationships.

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).

SAN ANTONIO – Cognitive-behavioral therapy, or CBT, can be effectively used during brief sessions in certain cases.

For example, brief CBT sessions can be useful in patients with Axis I disorders for which pharmacotherapy is being used effectively, and in patients in whom symptom complexity does not appear to require longer sessions, Dr. Donna M. Sudak and Dr. Jesse H. Wright said during a premeeting workshop at the annual meeting of the American College of Psychiatrists.

Other patients for whom brief CBT sessions might be indicated include inpatients; those with a preference for shorter sessions; those on long-term pharmacotherapy; and those with illnesses for which brief treatment may be advantageous, including psychosis, bipolar disorder, obsessive-compulsive disorder, uncomplicated anxiety disorders, and substance abuse requiring frequent visits, according to Dr. Sudak, professor and director of the psychotherapy training program at Drexel University, Philadelphia, and Dr. Wright, professor and director of the Depression Center at the University of Louisville (Ky.).

The format for providing brief CBT sessions can vary. For some patients, an initial evaluation followed by brief sessions might be appropriate. Other patients might be best served with several 50-minute sessions, followed by a transition to brief sessions later in treatment. Some patients might require a mixture of 50-minute and brief sessions, and some might do well with a team approach in which a psychiatrist provides brief sessions and a nonphysician CBT-trained therapist provides longer sessions or a nonphysician therapist provides therapy from a different orientation.

The selected format should be based on the patient’s need and preference, and can change over time, Dr. Wright said, noting that many patients prefer brief sessions because of time constraints.

Numerous high-yield interventions can be used in brief CBT sessions. Some examples include adherence enhancement; behavioral activation, which is particularly potent for treating depression; breathing retraining; CBT for insomnia, which is an area of increasing interest; cognitive-behavioral rehearsal; collaborative empiricism; collaborative goal setting; computer-assisted CBT; eliciting of and modification of automatic thoughts; exposure; cognitive error identification; motivational interviewing; psychoeducation; and relapse prevention.

Dr. Sudak and Dr. Wright shared several strategies aimed at enhancing the effect of brief CBT sessions.

Improving each session

First, make certain to have a clear formulation of the patient, they said.

Key elements of the formulation include diagnosis and symptoms; formative influences; situational issues and biological factors; strengths and assets; cross-sectional and longitudinal formulation; and a working hypothesis and treatment plan that is developed based on how all of these factors "pull together to influence the way this person thinks about the world, and [her] skill set in terms of working with other people and managing [her] own emotions."

Miniformulations developed during the course of care also can be helpful. These formulations address a specific issue that needs to be addressed "right now." Such formulations are collaboratively developed, simple and easily understood, and provide targeted direction for therapy interventions.

Dr. Sudak said she will sometimes draw a miniformulation on a whiteboard during a session, and will have the patient draw the same on a piece of paper to take home. She gave an example involving a "feedback loop" in a patient who hears teenage girls laughing while he is walking to the store. He experiences the thought that they are laughing at him, and that they therefore must think he is "a loser." This causes feelings of fear and sadness, leading him to keep his eyes down and return home without going to the store.

The miniformulation in this case involved drawing a circular graphic to outline the feedback loop and work on strategies for developing more realistic, healthier thoughts about being out in public, and for working on becoming more comfortable around other people, gradually increasing the ability to be in public settings.

A specific treatment plan should be developed for each session based on these formulations.

Techniques used in the course of treatment should include those that are most likely to be effective in briefer formats. Particularly high-yield techniques for brief CBT sessions include adherence enhancement, behavioral activation, and thought change records.

Also, special attention should be paid to the relationship and to pacing.

Enhancing the therapeutic relationship is important regardless of session length, but is particularly important for brief sessions, Dr. Wright said.

Helpful techniques for relationship building include emphasizing a team approach with shared responsibility; staying tuned to the patient’s emotion – and responding with accurate empathy; giving the patient your full attention and avoiding digressions; choosing targets for change with high relevance and opportunities for success; and building communication skills. In addition, listening carefully, giving clear explanations, summarizing key points, and asking for and giving feedback help build relationships.

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).