Sunday, 27 September 2009

Giving a rationale for CBT

Some clients (or patients) may come to CBT (cognitive behavioural therapy) knowing exactly what CBT is and how it will benefit them. However the majority probably won't - they may be ambivalent about the therapy and start with misconceptions about CBT.

If they understand the potential of CBT for them it will not only increase their motivation but also give them a better opportunity to engage fully in the collaborative CBT process. So it's a good idea to provide a rationale for CBT, and explain how it works, early on in the first session.

So how best to do this?

Here are some alternative ways to present CBT to the client in the first session
1) Give a handout on CBT for the client to read after the session
2) Explain the CBT rationale in session using short case vignettes and a diagram
3) Use similes and metaphors to tell the client what CBT is like.
4) Use a "naturally occuring moment" to link the client's own situation to how CBT can help them.

Imagine you were a CBT client, which would you prefer?

In my view, all of these have a place, but as you'll see I do have a view as to which is usually preferable.

Giving a handout on CBT means you have more time to work on an assessment in the first session, and also means the client can read about CBT in their own time and at their own pace. You could base such a handout on the information given in  Tim LeBon's CBT website.
But the disadvantages of just giving a handout are many. How many handouts have you been given and haven't actually read? What if the client misunderstands the material or has lots of questions it? Worse still, what if the client decides in the first session that CBT isn't for them, because they haven't understood CBT and its rationale properly - so they never bother to read the handout. For these reasons, I would recommend using handouts as a supplement rather than as the main way to explain CBT's rationale. I wonder if the same applies to use of handouts and readings in general - use them as a helpful extra that will be of benefit to the more motivated client, but don't rely on them.

What about using case vignettes and pre-prepared diagrams to help explain CBT in the first session? Again, this can be a useful approach. Have a look here for a good example of material to base this on and here is another, shorter explanation of CBT. You can present the "hot cross bun" model from Mind over Mood or perhaps an ABC account. The ABC account states that the activating event (A) doesn't lead directly to the behavioural and emotional consequences (C) - the beliefs (B) come in between them. Changing your beliefs  provide scope for changing the consequences, whatever the event. These can be made more vivid if you have a store of case vignettes to show how ABC and the hot cross bun works, preferably choosing a case close to the client's presentation.
In my view presenting the CBT model and brief cases is preferable to just giving a handout, but presents different risks. Most obviously, it can turn the first CBT session into a lecture - not good for any form of counselling, even less so for CBT which emphasies  teamwork and collaboration. So any "mini-lectures" needs to be done in a simple and concise manner, checking out that it makes sense to the client at regular intervals. It also really does need to be "mini" - no more than five minutes, preferably less.
But what if the client objects to some of the ideas you present? Instead of getting defensive, welcome these objections as signs of client engagement. Get the client interested in testing out their ideas empirically - it could even lead to an early behavioural experiment.
A third, more imaginative, way to help the client understand CBT  is for you to provide similes and metaphors for CBT in the first session. So you say to the client "Getting CBT is like going to a yoga class in some ways - you learn skills but to get the main benefit you have to practice them outside." This can be particularly important if the client expects CBT to be either like going to the doctors - where you take away a prescription and don't need to do any work outside sessions - or client-centred counselling and psychoanalysis, where the work happens mainly in the sessions rather than outside them.
Can you think of other good analogies for  good CBT ? Here are some to start to you off.
Good CBT is like
  • learning to drive
  • learning to cook
  • going to a yoga class
  • having golf lessons
Post a comment if you can think of any other good analogies for CBT.
    The ideas to convey are that a CBT session involves learning skills and practising outside sessions. You can also use similes and metaphors to help get across the rationale for CBT - for example "CBT is like a mind gym" or "Cognitive therapy is a workout for the brain". Using similes is certainly a good idea, and might help persuade the client -but way not be sufficient on its own,  as it doesnt explain the 5 part  model or the link between thoughts and their consequences.

    The fourth - and in my view best- way to provide an explanation and rationale for CBT in the first session with a client is to use "naturally occuring moments" to link the client's own situation to how CBT can help them. Here is one way this might work out
    Therapist: Thanks for coming today. As you know, we are going to be using an approach called cognitive behavioural therapy (or CBT) to help with your problems. Would you like to hear a little about this approach and how it works?
    Client: By all means.
    Therapist: The basic idea in CBT is that how we think affects how we feel -and also what we do - and vice-versa. Does that make sense?
    Client: I'm not sure. What do you mean exactly?
    Therapist: Well, let's start with how we think affecting how we feel. What are you thinking at the moment?
    Client: Well, to be honest I'm a bit sceptical about CBT! Will it work for me? Can you really think your way to happiness?
    Therapist: And what emotion are you experiencing when you think "CBT might not work for me?"
    Client: Rather down, a bit hopeless, I guess.
    Therapist: And what emotion might another client be experiencing if they were thinking "CBT makes a lot of sense"
    Client: Probably more hopeful.
    Therapist: So here we have the same situation - a client coming for CBT for first time, two different thoughts "CBT might not work for me" and "CBT makes sense" and two different emotions.
    Does the idea that how and what you think affects what you feel make more sense now?
    Client: Yes, it does actually. I do see how my thinking affected my feelings today.
    Therapist: And what are you feeling now?
    Client: Rather more hopeful, actually!
    Therapist: That's a great start then. Now shall we see how this might help with the problems you'd like help with ....

    You can then move on to working on the assessment and formuation, with the client's interest in how the cognitive model might apply to them being ignited in a way that might be missing from the other three approaches.

    Whichever method or combination of methods you use, hopefully this post provides some ideas about how best to share some information and a rationale for CBT in the first session with a client.


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