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The agenda-setting process in a CBT session

What is agenda setting, and why is important?

Agenda setting is a collaborative process through which the therapist and patient decide how session time will be spent. The patient and therapist offer items they would like to discuss and then decide the order of items and the amount of time they will spend on each. Each item should be in service of treatment goals (see Module 6: Goal Setting and Module 4: Cognitive Behavioral Case Conceptualization and Treatment Planning). Agenda setting ensures session that time is well spent and that both therapist and patient have input into session content.

Typical Session Outline

Briefly review patient’s mood and/or physical functioning (5 minutes). Elicit responses concerning the patient’s mood, and consider any and all discrepancies (e.g., change in strength or nature of usual mood, change from last week or beginning of treatment). Medically ill patients may benefit from regular assessments and updates on their physical health symptoms and functioning. Also ask the patient to offer explanations for mood improvement or decline. This brief update allows you to gauge how the patient is progressing and identify positive and negative change. If medication management or physician collaboration is part of the patient’s treatment, this is also a good time to check on any side-effects the patient might be having from medication and make adjustments as needed.

Bridge discussion from previous session with the current session (5 minutes). In bridging sessions, you are checking the patient’s understanding of what was discussed in the previous session. Reinforcing what the patient learned in past sessions is essential to the improvement that the patient makes outside the therapeutic relationship. Having the patient complete a Bridging Worksheet can assist in this stage of the agenda. Some issues discussed during this phase could become items on the agenda for the current session.

Set the agenda for the current session, and prioritize the items (5 minutes). First ask the patient what he/she would like to discus, and then offer an item. If a patient brings several agenda items, he or she might need to indicate which is the most important to discuss first. When a situation (e.g., fight with boyfriend followed by food binge) is offered by the patient as an item, you can use the situation as part of his/her agenda item, that is, as part of the skill being taught. For example, you can use the above scenario to teach/review a thought record.

Review any homework given in the previous session (5-10 minutes). Patients who do between-session homework show greater improvements than those who do not. To reinforce and troubleshoot between-session learning, it is important to review homework. In session review serves two purposes: it reinforces the importance of homework and allows you to assess skill acquisition. If you identify errors in homework, you can use additional session time to review the skill. Reviewing homework can take a small amount of time; or it can take the entire session, depending on what the patient has learned from doing it and what difficulties he or she has encountered in completing it.

Discuss agenda items and set up homework (20-25 minutes). Discuss agenda items, starting with the first and most important. If you are running short on time, inform the patient that you will discuss the other items at your next appointment. Set up homework that is directly connected to what has been discussed in the session.

Summarize the current session and exchange feedback (5 minutes). Two types of summarizing are recommended. The first is a brief summary that should be done after the conclusion of each section of the agenda to reinforce what has been discussed. The second type is used to clarify and remind the patient of the thoughts he/she has presented and how those thoughts changed as a result of the exercise. It is important to use the patient’s specific words in summarizing his or her thoughts. At the end of the session, summarize the main points of the entire session. As the sessions progress, ask patients to do the summaries. Finally, exchange feedback about the session, skill, or progress of therapy. This is a time for you to encourage and motivate patients to continue working towards change.

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