Wednesday, 18 March 2015

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?