Sunday, 28 October 2018

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.