8 things to do in the first session of CBT

1. Do the usual things that need to happen in a therapy assessment. unless they you already have this information. The information you need  includes  demographics, previous psychological interventions, family history, medication and lifestyle (diet, exercise, alcohol and drug use) . Since these are not specific to CBT, in my view its a good idea for a service to elicit this information for all clients so that your first session can focus on the CBT. If you work in private practice, you might decide to ask for this information by email or in a quick phone call. If you haven't got this information before the first appointment, you need to allow extra time for the first session otherwise you won't get much CBT done. If you don't get much CBT done in the first session, the danger is the client won't come back because nothing useful has happened in the first session.
2. Read all the information you have about the client before you meet them. This need take no longer than 5 minutes.. I will never get going with my son for an appointment to his allergy clinic. The doctor, who had actually seen him before, clearly remembered nothing about him and had to ask all the basic questions again Two minutes reviewing her notes would have made all the difference. What message does it give if  a patient  if the therapist doesn't  know basic things about you that you have already told them (or someone else in their service)?
3. Do an MDS (including PHQ9 for depression and GAD7 for anxiety) and a risk  assessment. Ask about risk even if this has been done in a prior call as it may have changed. When doing the MDS, its worth asking for specifics as this gives you extra information. for example if they have answered yes to the question positively to the question about sleep, ask whether its sleeping too little, too much or not getting or staying asleep. For this reason, in the first session I prefer to ask them the questions rather than have them fill it in, though in subsequent sessions it saves time if patients fill in the MDS before the session..
4. Socialise the patient into CBT. I have written another post to suggest good ways to do this. This is an important part of the first session, especially for clients who have had a different form of therapy before (in which case you might need to emphasise the difference) or have had no therapy.
5. Find out their initial problems and goals.  I see the problem as being the clinical window on their treatment - such as depression, anxiety, OCD or social anxiety.  Goals are the client's view of what they want from CBT. These will often typically be expressed as "Feel like I used to" or "Be happy" in which case you need to spend some time getting the goals into shape. At this stage, they don't have to be fully SMART but here are 2 rules I follow for initial goal-setting.
a) Make sure they are positive - if someones says "not feel depressed" ask "what will you be doing once you are not depressed?"
b) Make sure they are behavioural. If a patient says "I want to feel happy" ask "once you are happy, what would a fly on the wall notice you doing differently"
Ask about which is the most urgent and important problem for them to work on.
6. Do an initial  formulation. This will often be a five areas model or hot cross bun on the main problem. For any PWPS reading this, you can use the problem statement to the same effect.
For instance, if someone says that the main problem is depression, then do a five areas assessment of depression.  There are 3 very good reasons for doing this
a) It further socialises the patient into CBT. They go in to the session knowing they are depressed, they come out realising that their behaviours, avoidance and thinking is whats keeping them depressed
b) It aids your treatment plan. Its always tempting to launch into treatment before the formulation but think about it - it would be like your dentist deciding on treatment before getting the x-ray results.
c) It aids collaboration and reduces resistance. Most of this initial session is information-gathering or information-giving. This is the part where you start working together on the problem
If the problem is known to be one for which we have a good disorder specific model, there is a strong case for launching straight into the disorder specific model. For example with panic you could go straight to Clarks model. If you stick with the 5 areas model in the first session, then make sure you ask questions informed by the model - such as "What do you notice going on in your body when you start to feel anxious?" and "What thoughts do you have about what is going on in your body?"
7. Set appropriate homework (which I prefer to call home practice or better still daily practice)
This should follow naturally from what has happened in the session. Examples of potentially good homework might be
a) working on making the goals smarter
b) Reading psycho-educational material (for example about fight/flight reaction)
c) taking away a copy of ihe initial 5 areas formulation and reviewing it
d) keeping a 5 areas diary relating ot the problem being prioritised
e) If you sense ambivalence, asking the patient to write down the pros and cons for working on this
8 Elicit feedback on the session.  How did you find this session" and "What was the most important thing you will take from it"  and "How do you think CBT could help you?" are good questions.

A small thing that could make a big difference if you supervise anyone

Do you supervise anyone as part of your clinical work?


Even if you do not think of yourself as a supervisor, you may find that as part of your work you do in effect take on  a supervisory role.

For example you may
* Do case management of a number of colleagues in an IAPT service
* Shadow trainees and provide feedback
* Be part of a supervision group, in which you are at times required to provide feedback
* Engage in peer supervision

Are you supervised yourself? Would you agree that being supervised can be quite stressful? Have you ever felt criticised in supervision? Have you ever felt really stressed, angry or upset during supervision? Have you ever  chosen not to share a case for fear of how the supervisor or your colleagues would respond?

If you have answered "yes" to any of these questions then join the club. I can answer "yes" to every one of these questions. Although it isn't often talked about, supervision can be a scarey place, where you lay open your soul and hope for the best.

It needn't be like this, though. Supervision can be a positive,  interesting, exciting, compassionatesetting for learning about what you do well as well what can be improved in your clinical work. As a supervisor, I find it very helpful to remember this especially when I notice a critical voice about to enter my head.

Whilst  positive supervision is of course  best expressed in the whole spirit in which you conduct supervision, there is one small thing I've introduced into my clinical practice  as a supervisor which I believe makes a big difference. It's this.



At the start of each session, I ask each supervisee a simple question

"Share with us one thing that has gone well in your work since we last met"

Often the supervisee has to think for a while, and then they come up with something. Maybe a difficult case that's gone surprisingly well, perhaps a difficult situation with colleagues that was resolved, sometimes an initiative they have introduced in the service or their private practive or a course they have delivered well.

As we discuss this the supervisee's  body language lifts and the atmosphere in the room becomes more relaxed and positive.

But that's not all. I then ask

"What did you do, what quality did you show, that helped make this thing go so well?"

Sometimes the supervisee will struggle to identify what it was exactly, in which case you can help them figure it out. More often than not though, they will be able to say "I was empathic", "I prepared well" or "I was assertive" or whatever it was that helped. Again, they will be pleased and the atmospher will lift.

Even more importantly you and they are learning about their strengths as a therapist. You can  feed their strengths  back to them in moments when they appear to be  doubting themelves. You can ask them if they can use the qualities they have identied as helping in the "What's gone well" exercise when they come to present cases they are struggling with. You can help them build a profile of their strengths as a therapist.

Why not give "What's gone well" a go the next time you supervise someone? Let us know whether you find it helpful, in the comments section below.

CBT or BA for depression? The verdict is in!

In 2015 I attended a talk at the BABCP conference given by Dave Richards telling us all about COBRA, a very large scale research project aimed at  determining whether stand-alone Behavioural Activation (BA) could be recommended as strongly as CBT for depression. The current NICE guidelines for Depression recommend CBT over BA - which,  whilst understandable given the sheer quantity of evidence for CBT - seemed to me a recommendation waiting to be revised.  Having used both BA and standard CBT for depression, I have found  BA components to be  very powerful.
Of course NICE can't recommend treatments on such clinical impressions. They need  hard evidence.
Enter COBRA - a massive 4 year, 440 participant study to test out whether depressed patients fared better with standard CBT or BA.  By 2015 many of the preliminary results were in, but Richards was not allowed to tell us anything about them at the BABCP conference.

Now the wait is over and the result is that

                      BA was found to be not inferior to CBT for depression

The wording is important - to encourage NICE to make BA an equal treatment of choice to CBT next time it updates its guidance for depression, the focus was on BA being as good as standard CBT.   The authors of the study hope that this finding will make treatment for depression more affordable, since BA can be provided by practitioners with less experience and for less money than fully qualified CBT practitioners.  The question I want to consider here is a different one.  How can COBRA help us  CBT practitioners o become more effective in treating depression.  You might like to read the full report here and come up with your own thoughts ...

Here are three things I take from the report ....

1) Learn more about  Behavioural Activation
The BA protocol used  in COBRA was described as follows :-

[BA Practitioners] delivered an individually tailored programme re-engaging participants with positive environmental stimuli and developing depression management strategies. Participants were encouraged to increase their contact with individually specified positive situations and reduce their avoidance of other situations. Specific BA techniques included identification of depressed behaviours, analysis of the triggers and consequences of depressed behaviours, monitoring of activities, development of alternative goal-orientated behaviours, scheduling of activities, and development of alternative behavioural responses to rumination

So BA is much more than just scheduling positive activities. It involves quite sophisticated functional analysis of depression and teaching of goal-orientated behaviours and anti-rumination techniques.

A number of good books are available to learn more - I would recommend

Manage your Mood by Robb Wilson and David Veale  as a self-help book and

Behavioural activation  for depression: A clincians Guide by Chris Martell et al. for therapists.

A good  brief introduction on the web can be found here

2) Incorporate BA techniques into your standard CBT treatment

The "standard CBT" protocol excluded some of  behavioural techniques that might easily be included into your CBT treatment for depression.

[CBT Practitioners] delivered a personalised treatment programme based on an assessment of how participants’ beliefs lead to emotional distress and ineffectual coping. Participants used cognitive and behavioural exercises to specifically test the accuracy of those beliefs by identifying and modifying negative thoughts and beliefs that give rise to them. Specific techniques included participants monitoring moods and activities, planning of exercises to test negative beliefs, and thought records to identify and examine the accuracy of negative automatic thoughts and underlying beliefs 

The CBT delivered appears to have been very cognitive, with the main behavioural compoment being behavioral experiments to test out beliefs.

There appears to be plenty of scope for incorporating more behavioural strategies into your CBT treatment - especially activity scheduling and anti-rumination techniques. Personally I have found that focussing on rumination has greatly benefitted many sufferers of depression.

3)  Develop an individualised formulation to decide whether to focus more on behavioural or cognitive methods

Good CBT is driven by an individualised formulation. Is your client depressed mainly because they are thinking negatively or because they have lost contact with enjoyment and a sense of achievement? Are they ruminating a lot?  Have they lost a sense of purpose? Is a negative view of themselves, the world and the future at the heart of their depression?  Do they know how to problem solve and set SMART goals?  Are they falling prey to a  lot of thinking traps? These and other questions (asked in assessment) can give you a good sense of where to focus your treatment. Your formulation can help you summarise this understanding of their depression and help you make the quickest wins
Of course, cognitive change can bring about behavioural change and vice-versa, so you probably dont have to go through every behavioural ("outside-in") and cognitive ("inside-out") strategy to achieve improvement. The idea here is to work out which element is causing the biggest problems and target that first.
The COBRA study does not directly provide evidence that such an approach would be superior to either BA or CBT as per the protocols followed.   However, it would appear to make a lot of sense.
What do you think?

Quiz - CBT for Specific Disorders

10 Things I learnt from Fiona Kennedy's Putting DBT into your practice 2 day workshop - Dialectical Behaviour Therapy

This excellent workshop wasn't intended as a complete training in DBT, but rather as a way to understand how an experienced practitioner could take parts of the DBT model and incorporate it into their practice. It worked for me! Here are the top 10 things I learnt from the course

1) DBT is Dialectical

Dialectical means accepting and working with opposites and apparent contradictions

There is a thesis, an antithesis and then a synthes which includes  truth from both.

• For example,  if the thesis is "I need to change!". 
• and  the antithesis is "I can't change". 
• the synthesis could be "Change is difficult. What I have tried so far hasn't worked. I need to work on skills to change, even though this will be difficult".

If  a client wants to practice midfulness (the thesis) but has a cold and says "I cant do mindfulness today because I have a cold" then as a therapist you might helpful suggest (the synthesis) "Your cold presents you with a great opportunity to practice mindfulness when its harder"

2) DBT is Behaviorial

The focus is on behaviours that need to be changed for the client to achieve their goals.  This provides a very clear focus and can make the complicated and complex much simpler
The therapy focuses on

What am I doing causing me and others problems and what can I do differently?

Below is a summary of some behavioural principles which can help guide a skilful therapist

• Form a plan to change unhelpful behaviours
• Get whole lot of possible solutions
• Give them skills ask them to choose like a smorgasbord then ask which appeals most
• Look at obstacles and how to overcome them
• Shape and reward desired action - if they have done something positive, praise this 

3) DBT is Skills-based

 Forming a plan is a good start, but many people don't have the skills to carry this out effectively. There is a large element of skills training in DBT and  this is usually done in Skills groups

where participants  learn to decrease problematic and unskillful behaviours.

Each module lasts about 6 weeks

The modules are:

Emotion regulation - what you can change - here are some good ideas about emotional regulation and article assessing cognitive strategies such as distraction and reappraisal

Distress tolerance - dealing with difficult emotions and what you cant change . Here is a useful handout on distress tolerance  and here are the CCI modules on distress tolerance
Mindfulness - learning to control your mind  - here is DBT's version of mindfulness and some free mp3 mindfulness recordings that can be used in DBT
Interpersonal skills -learning how to get your needs met regarding other people - here is information on DEAR MAN GIVE FAST ideas and some handouts on DBT and interpersonal effectiveness skills

There is typically a maximum of 8 in a group with  2 therapists. One talks the other "reads the room" 

As with learning any other skills, homework is key. If people don't do it, this needs to be dealt with.
"Did you think of it or did you forget it?". The failure to do homework is problem-solved.

Here is a really useful free 85 page DBT Skills Booklet that can be used in a group

4) A possibly lengthy assessment phase

DBT is a big investment for both client and therapist. It is fitting then that some time is given for the potential client to think about whether to commit to DBT.
A Contract usually a year involving a lot. Asssement will explore motivation and behaviours they want to change. This phase can last up to  6 weeks

5)Telephone coaching is part of the deal

In a DBT group, the client is offered  telephone coaching when they need it. This is specifically for help when they are in crisis. The client will form a crisis plan which they have with them
If they ring, you go through the crisis plan with them
"Get them to breathe then walk through plan"

6)Validation and Acceptance of the  client

Although change is the desired outcome, validation is an extremely important prerequisite for change

There are 6 levels of validation

These range from showing an interest, to validating their emotions and behaviours "It's normal to feel anxious before coming to see a therapist." You are accepting the person, but that doesn't mean you are endorsing unhelpful behaviours.

7) Use of Chaining as a formulation method 

This is similar but not identical to CBT's "Hot Cross Bun" or "maintenance cycle" formulation is called "Chaining" in DBT.

Chaining is actually fairly straightforward and involves the following steps :-
Ask

• When did you first know that  the problem behaviour would arise?
• If you were in situation again what would you do differently?
• What stopped you this time?
• What made you vulnerable at this time

• What happened when you stopped
• What are the consequences?
• What can we learn from this?

Then ask them to describe the sequence as if telling an actor how to play the part. It needs to be spefific. You are finding out the chain of antecedants, behaviours and consequences in terms of thoughts, feelings, urges and behaviours.

This article provides a really good detailed account of chaining

8) The Role of individual sessions

A lot of the skills learning takes place in the group sessions, but individal sessions are important too. In these you make list of target unhelpful behaviours to reduce 

In each session work through list in each area hierarchically

They bring in diary/ Your job is to keep them "on the hook" 

9) Wise Mind

DBT makes the helpful distinction between Logical. Emotional  and wise mind
Logic is great - but what it would be like to be just in logical mind, like Mr Spock?
We would lose a large part of what it is to be human, what motivates us and what makes us individual.  Fear keeps us safe. Anger stops people treating us like a doormat

Yet emotions can get us into a lot of trouble.

We need emotions - but in moderation

Wise mind can moderate emotions, its the synthesis of logical mind and emotional mind.

Here is an exercise that might help you locate your own wise mind
Think of a dilemma

Start with facts and logic

Then think about the emotions and desires connected with the dilemma

Imagine falling  down  a well taking all the facts and feelings with you. At the bottom is
a trap door. Through this trap door is your wise mind, which takes into account logic and feelings. Go through the trap door? What does wise mind tell you is right for you?

Here are useful worksheets and  handouts about wise mind

10) Use of Metaphors 

Wise Mind is one metaphor used in DBT - there are lots of others that are used in DBT

For example

• Tigger and eeore
• If you want a decent life you have to experience the pain
• Change your home page 
• Thoughts can be like junk mail
• Make a lemonade out of lemons. 
• Need to go through pain barrier to get through marathon

Here is a link to other metaphors of use in therapy  a good article and a couple of really good books
Oxford Guide to Metaphors in CBT
Stories and Analogies in CBT

Further Resources


Free 85 page DBT Skills Booklet
Really comprehensive site full of free DBT resources

DBT® Skills Training Handouts and Worksheets

DBT Therapy Skills Book

There are also a number of Apps for clients to help develop DBT skills

How to do CBT (Part 3 of series)

This is the third and final  part of a series of articles about three ways of doing CBT with a hypothetical client, "John". 

John comes to CBT because of his depression.  He is a 40 year old who has recently been made redundant. He is worried about getting a job again and his redundancy has also  caused tension in his marriage. When questioned about how he spends his time now, he says he gets up late, intends to look for jobs but ends up doing very little. He feels demotivated, discouraged and, at times, hopeless.  He is having trouble sleeping and hints that he may be using drinking to cope with his difficulties.  At times, he says, he wonders if he will ever get a job again.  He sees his redundancy as meaning that he is a failure.  He talks in  a flat, slow monotone. As he talks, he is becoming more sad and more hopeless.

In the first article, counsellor A had a  short car-crash session, in the second article counsellor B  if anything  did even worse.  Yet both included good evidence-based CBT ideas ... Now we will see how counsellor C takes a somewhat different approach so the session lasts a bit longer ...

How to do CBT: Counsellor C with John

C1: Good to see you again, John,  I can see from the PHQ9 scores you filled in whilst you were waiting that it’s been quite a tough week but there’s been some improvement. Is that how it seems to you?

J1:  I didn’t realise there had been improvement. Still feels pretty grim at times to be honest

C2: Sorry to hear that – shall we put that as one of the items on our agenda for today?

J2: OK

C3: What shall we put?

J3: “Feeling pretty grim at times?”

C4; OK … Just at times?

J4: Well, probably quite a lot of the time to be honest

C5: OK, I’ve written here under Agenda – “ 1. Addressing feeling grim a quite a lot of the time.”. OK?

J5: Yes

C6; Now we have an ongoing agenda item – review homework – so we’ll do that first as usual. I’d also like to add to the agenda –“pros and cons of being active” – is there anything else you would like to add?

J5: Well, to be honest I’ve been wondering whether I’m wasting your time.

C7: OK, that’s something we should definitely add to the agenda (writes down “Am I wasting counsellor’s time?”).  We’ll look at that more fully later,  but can you just say a little now about why you think you are wasting my time?

J6: I still haven’t got a job. I still waste most of my time.  I’m a waste of space ….

C8: It sounds like that’s definitely an important thing for us to look at. We’ve got 4 things on our agenda – review homework, Address feeling grim, pros and cons of being active and am I wasting counsellor’s time. I’m wondering whether that might be a good order to look at things? I’m thinking that later in the session we might have a better idea about how useful this process is for you.

J7 : That makes sense.

C9: So, how did you get on with the  homework?

J8: (Gets sheet out of pocket) Here it is.

C10: Would you like to talk me through it?

J9:OK …Well, on Wednesday I didn’t feel great, I didn’t really feel like going out  but I had a letter to post so went into town and actually it looks like my mood did go up from a 4 to a 5. Then the rest of the day wasn’t so bad. Thursday was bad though. I woke up feeling totally lacking in energy.   I stayed in bed .. didn’t get up until 200. Then it felt like it was too late to do anything. Then later in the evening I felt even worse, thinking “I’ve wasted the day, I’m never going to get better.”

C11: And what happened to your mood on Thursday?

J10: It started at 3 – then went down to a 2 in the evening. Not great.

C12: No, it doesn’t sound like a good day at all. Still, hat was a great effort to fill the forms in even though you were feeling so low. Well done. Shall we look at the two days together and see what we can learn from them?

J11: Sure

C12: So on Wednesday, you didn’t feel like going out, but do did and then you felt better. What can we learn from that?

J12: Maybe that being active helps, but that sometimes we don’t feel like being active.

C13: Exactly. So should we always do what we feel like doing?

J13: No, because actually  I felt better after I did what I didn’t feel like doing

C14: That’s a very important insight you’ve captured there, John. We often do feel better when we are more active. But when depressed we don’t feel like being active. So what have we got to do to lift the depression?

J14: Be active even when we don’t feel like it?

C15: Exactly. How would you feel about trying that as part of the homework for next week?

J15: I’ll try.

C16: Let’s write it down. “Last weeks’ homework suggests that it will help to be active even when I don’t feel like it.” What else do we need to record?

J16: Maybe how I feel about being active at the time?

C17: Right, so let’s add another column to your record sheet – “How I feel about being active”. How does that sound? Can you imagine recording this?

J17: Yes

C18: Do you think it might be helpful?

J18: Yes

C19: OK – just to make certain, let’s see how that might have panned out on Thursday. If you’d been tracking your thoughts then as well, what would you have written down?

J19: Let me think. Probably “I’ve no energy so I’ll stay in bed?”

C20: Bearing in mind what we’ve just learnt, what do you think now?

J20: Even though I don’t feel like being active, if I do I’ll feel better

C21. Great. So I’m wondering if we need another column, like this (Adds another column –“more helpful thought.”) How does that look?

J21: Looks good – not sure though if it will work though if I am feeling as low as I did on Thursday.

C22: Is it worth trying?

J22: Yes, it’s worth a try.

J23: How are you feeling now about our work today so far?

J22: Good

C23: Me too.. Shall we take stock. So far today we’ve reviewed the homework, and seen that on the day when you are more active, you feel better. So we have set up a homework task next week where you notice negative thoughts telling you not to be active, and do your best at answering back to them and then being active – again recording how you feel afterwards. Have I missed anything?

J23: No

C24: So  shall we move on to the other agenda items. We had  “wasting my time” –do you still think you are wasting my time?

J24; No, not nearly so much

C25: Good, neither do I. Shall we move on to the next item on our agenda?

J25: Yes.

What did counsellor C do differently?

Another song for depression : Better get to livin' by Dolly Parton

By: Dolly Parton & Kent Wells

People always comin' up to me and askin' 
"Dolly, what's your secret? 
With all you do, your attitude 
Just seems to be so good 
How do you keep it?" 
Well I'm not the Dalai Lama, but I'll try 
To offer up a few words of advice

Chorus:

You better get to livin', givin'
Don't forget to throw in a little forgivin'
And lovin' on the way
You better get to knowin', showin'
A little bit more concerned about where you're goin'
Just a word unto the wise
You better get to livin'

A girlfriend came to my house
Started cryin' on my shoulder Sunday evening
She was spinnin' such a sad tale
I could not believe the yarn that she was weavin'
So negative the words she had to say
I said if I had a violin I'd play

I said you'd better get to livin', givin'
Be willing and forgivin'
Cause all healing has to start with you
You better stop whining, pining
Get your dreams in line
And then just shine, design, refine
Until they come true
And you better get to livin'

Your life's a wreck, your house is mess
And your wardrobe way outdated
All your plans just keep on falling through
Overweight and under paid, under appreciated
I'm no guru, but I'll tell you
This I know is true

You better get to livin', givin'
A little more thought about bein'
A little more willin' to make a better way
Don't sweat the small stuff
Keep your chin up
Just hang tough
And if it gets too rough
Fall on your knees and pray
And do that everyday
Then you'll get to livin'

The day we're born we start to die
Don't waste one minute of this life
Get to livin'
Share your dreams and share your laughter
Make some points for the great hereafter

Better start carin'
Better start sharin'
Better start tryin'
Better start smiling
And you better get to livin'

Dolly Parton has spoken about her own history of depression   The "Better get to living"  idea is non-pharmeceutical anti-depressant.