Wednesday, 12 June 2013

How to engage and socialise clients into CBT more quickly

The other day  I had an unbalanced yet illuminating psychotherapy day. Of the 5 clients I saw, 4 were just starting therapy, either having an assessment or in their early sessions, and the other was at session 12, near the end of her therapy journey.

For the client nearing the end of therapy , the session almost ran itself. We quickly settled on an agenda, reviewed home practice and then the client herself was able to apply the formulation and new ways of thinking and behaving to her issues. It felt like real teamwork, and we both left the session  feeling  really good about it. I felt full of energy and enthusiasm

With the other clients  it was a different story. I was spending a lot of time and energy keeping the structure of the session tight, dealing with any doubts the client had about CBT  and trying to match what they were saying and what they wanted with how  CBT understands things and what it can offer. I do not know how these clients felt about the sessions, but I felt drained and wishing I could  have done a better job.

The contrast could not have been greater. Yet that the first client had been just like the other clients a few months ago. She and I had climbed the CBT mountain and now it was all  downhill, in a good way.

My question is this. How can we CBT therapists get to the top of the CBT mountain more quickly? How can we get to that wonderful feeling of teamwork, collaboration and fruitful work being done in 3 sessions rather than 5? How can we have less clients needlessly dropping out of treatment?

Here are some thoughts

  • Explain to the client that the first sessions aren't so much about curing the problem as understanding it-this sets the scene for formulation work. 
  • Use disorder-specific models when you can - they provide a compass for you to follow
  • Use metaphors, similes and stories as part of the psycheducation. For example if dealing with OCD, you may ask the client to think of OCD as being like a school bully that keeps asking for more
  • Give appropriate reading as part of psychoeducation - my experience here is that less is more, and a sheet has much more chance of being read and digested than a book.
  • Ask the client to be actively involved in psychoeducation. "Which parts of the article apply to you?" "What are you unsure about?" are good questions.
  • Use guided discovery to convey the CBT model and aspects of it
  • Look for examples in the client's story that fits with CBT and draw their attention to it
  • Summarise  more frequently than in later sessions , and ask the client to summarise back
  • Ask the client at the end and beginning of session what was most important thing from the session (or previous session)
  • Be structured right from the start and explain why CBT is structured. This gives you permission to politely interrupt the client if necessary
  • Set home practice right from the start of therapy and explain its vital importance
  • Ask the client to set their therapy goals early on in therapy and to grade where they are on them and keep coming back to them

What else do you think is important in the early sessions of therapy to help to get to the top of the CBT mountain more quickly?