The second CBT session
finishing the assessment and making a longitudinal formulation and diagnosis (part 1)
I have split this blog about the second CBT session into two parts. This isn’t because I somehow cover an enormous amount of ground in the second session, but because I’m keen to explain what I do carefully, including my scripts, and this will exceed an easy ten minute read. So here’s part 1.
Going into session two, I’m often aware of an unvoiced client expectation to ‘just get on and start treatment’. This is perhaps particularly noticeable in the private sector, where people are often paying handsomely for therapy.
Therefore, I invariably begin session two by recapping what we achieved in the first:
‘Last time, we came to a common understanding of the problems you’ve got right now and we drew them up on the board. This week, we’ll explore further in order to see how these problems might have developed from experiences in your past and we’ll draw these up too. Hopefully by the end, we will have a working diagnosis that explains your symptoms. We occasionally revise this diagnosis if new information comes to light during therapy, but it’s important that we do make a working diagnosis. This is because the treatment interventions that we will use are based on scientific evidence – there’s a lot of research that shows what interventions work for which particular mental health conditions. How does this sound to you for today?’
My aims for this session are therefore to:
- Largely finish the assessment
- Draw up a collaboratively created, general (non-condition specific) longitudinal formulation on the white-board
- Make (and share) a working diagnosis of the client’s condition
From the client’s perspective, this session delivers a stretched self-understanding, contextualizes how their life journey has lead to their present day problems and crucially, helps them to understand what is maintaining their distress.
From my perspective as therapist, this session is primarily about pattern recognition. Each mental disorder has characteristic patterns of problematic thoughts, behaviours and feelings associated with it. The practice of CBT (like any other clinical work) is therefore essentially about recognising these patterns. This is done by asking open ‘discovery’ questions and following promising lines of enquiry, guided by some knowledge of CBT theory, until sufficient evidence has accumulated to suggest a working diagnosis.
I follow the introductory agenda-setting preamble (as above) by reviewing their session one homework Mood Diary. If the client hasn’t done this for whatever reason, I ask them instead to describe a couple of distressing situations that occurred in the preceding week. Either way, this allows us to elicit further problematic patterns of thoughts, emotions, physical sensations and behaviours.
As the client speaks, I will be looking to see if patterns specific to particular conditions are beginning to emerge through analysing these several triggering situations. These patterns may expand/confirm/cast doubt or even refute my emerging hypothesis about the working diagnosis.
I also specifically ask about mental images that the client may experience. As well as having thoughts, some people often experience images, ‘seeing things in the mind’s eye’ or ‘hearing in the mind’s ear’. Most clients will not spontaneously offer up their imagery unless asked directly, often because they don’t think to do so, or because they consider imagery as childish or shameful or a sign that they ‘are really going mad’.
I then ask about the consequences that these problems are having in the client’s life. The consequences are best described by asking the client:
‘How has your life changed because of these problems? What can’t you do currently because of these problems? If these problems went away, how would your life look different from how it is now? How have those people who are important to you responded to your problems? What coping strategies have you tried and how successful have they been?’
These questions often shed light on what processes are maintaining the problems.
This information, along with that from the session one ‘hot cross bun’ formulation, allows us to create a problem list, which we can enter into the longitudinal formulation. My preferred general longitudinal formulation is the one from the Oxford Cognitive Therapy Centre (OCTC, 2009) – available by cutting and pasting this address into your search engine
https://www.getselfhelp.co.uk/docs/basicformulation.pdf
I suggest that you have a copy of this formulation to hand whilst reading the rest of this article, which continues in part 2.
Summary points
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The second session is essentially about recognising patterns of thoughts, feelings and behaviours that characteristically occur with particular diagnoses
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Review the Mood Diary to generate a couple more hot-cross bun formulations of the client’s current problems
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Ask specifically about images as well as thoughts
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Ask about the consequences of the problems
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Create a problem list