The first CBT session
assessment and formulation of the presenting problems
Several of my CBT textbooks dedicate up to 40 pages on how to do the CBT assessment. Fair enough – they provide a comprehensive overview of what to do and details of how to do it. But having entered the chapter and explored its furthest reaches, it’s easy to lose sight of the wood for the sheer number and type of trees around!
I have therefore found it helpful to structure the assessment in the first session around the following two themes:
- Is CBT with me the right treatment for this client, at this particular point in their life?
- Using the assessment process itself to model the CBT model (I guess you could call this meta-modelling!) and to make an individualised formulation of the client’s current problems
I usually start the session with a script that highlights these themes. Of course, you will have your own form of words but I’m offering up mine, in case this is helpful.
'Today, I’m interested in establishing your suitability for this kind of treatment – is CBT right for you at this point in time and if so, and how will it actually help you with your problems? If it isn’t, then we’ll consider what else might be available. That’s what I’d like to get out of this session. Is there anything else specifically that you’d like to get out of our time together today?’
This sets the agenda up nicely for the session. It also models a collaborative spirit to the otherwise largely therapist–directed agenda in this first session. In practice, clients rarely add anything substantially different to the agenda in answer to the last question.
I then begin the assessment by saying:
‘It would be very helpful if you can cast your mind back to a situation in the last seven days in which you felt very distressed. Can you start by describing the situation please? Then we’ll dive into the detail of what was going on for you in the moment when you were at your most distressed in that situation.’
Note that the focus of this session is squarely on the client’s current problems.
I then use a funnel style of questioning to structure my assessment of their presenting problems.
Figure: funnel style of questionning
I write the cross sectional 'hot cross bun' formulation up on the whiteboard during the session. Most clients will see that their own feelings, thoughts and behaviours were linked in the specific situation described. Time usually allows for us to look at a second specific situation in some detail too.
I then generalise back from their own examples to explain how CBT works, using the following script:
‘CBT is based on the observation that the way that we think and the way that we behave and the way that we feel emotionally and physically, are all closely connected. Furthermore they also work together in a single system, with each component keeping every other component going. And we have shown this on the board using the specific situation you just told me about. Naturally the situation doesn’t occur in a void, it occurs in the context of your environment. This means your current environment, like your job or family or society in general and your past environment, including your developmental experiences.’
Figure: the cross sectional, ‘hot cross bun’ formulation of the client’s problems
‘These double- headed arrows show the inter-relationships between all the components, so that the whole thing works as a system. CBT works like any system - the great thing is that you only have to change one component of it for the impact to be felt across all of it, so that in fact the whole system shifts.
So if metaphorically, the arrows linking the boxes were made of elastic bands, and we picked up the box labeled ‘behaviour’ and pulled it to the left, it would increase tension on the other boxes too. All the arrows would stretch a bit and at first, the other boxes would resist and try to pull the behaviour box back. This means that in the early stages of CBT, a person sometimes get an upsurge in the other symptoms initially. But if you stick with holding the behaviour box in its new position over here on the left, and be persistent, quite soon, the whole system shifts over.
Metaphorically that’s what I’m helping clients do in CBT – I’m helping them to identify more helpful tweaks to their behaviours and thoughts, so that they start to feel better physically and emotionally. This means that clients are learning lots of new skills and techniques, starting with identifying and monitoring feelings and thoughts, then moving onto to generating more realistic and helpful thoughts and behaviours and putting them into practice between sessions as homework assignments. CBT is a practical therapy in which you will learn new skills to take away with you into real life – does this sound like the kind of treatment you’d be willing to invest your time and energy into currently?’
This approach has been successful for me in selecting out the occasional client who either wants the therapeutic work to be in the act of talking and being listened to (i.e. counselling) or who cannot make a logistical or psychological commitment to regular attendance and practice between sessions.
It’s also important in the first session assessment to find out if the client is at particularly high risk of self-harm or suicidality – if so, discussion with your supervisor may suggest a more urgent intervention is needed, or that the client is less suitable for a trainee caseload.
Finally, I reinforce the CBT model of active skills-acquisition by giving them a Mood Diary to complete for homework. It’s important to talk through the rationale for using it and how to use it in as much detail as necessary. And that’s it.
Summary points
-
Is CBT right for this patient right now?
-
Use the assessment process to model and explain the CBT model itself
-
Use a funnel style of questioning to elicit information about the current problems
-
Generate a hot-cross bun formulation of the current problems
-
Assess risk and manage appropriately
-
Set the first homework, usually a Mood Diary
Reference: Padesky 5 Aspects, 1986, available from https://www.getselfhelp.co.uk/docs/5aspects.pdf
With thanks to Tanya Woolf at Efficacy for introducing me to the elastic band metaphor.
https://www.efficacy.org.uk/therapy/