2 First contacts with the client First contacts with the client may set the tone for future contact for therapyInitial contacts are crucial in moving the client from ‘demoralisation’ to ‘remoralisation’Initial contacts can be reinforced with follow-up materials - e.g., information sheets, etc.
3 Client suitability for CBT Inclusion criteria: e.g., has access to thoughts and feelings BUT true of all therapy?Exclusion criteria: psychosis BUT again true for all therapy?PARADOX: often difficult to know if someone is suitable until you try, and then if you decide that they are not suitable, it may be difficult to terminate
4 Questions to assess suitability after 3 or 4 sessions Does the client seem more or less hopeful now?Is there collaboration?Are clear and realistic goals emerging?What is the balance of work and responsibility between therapist and client?
5 Cross-sectional assessment What is the current problem?What keeps the problem going?How did the problem develop?What are the roots of the problem?What other factors such as health of client could be involved?What are the client’s expectations of and goals for therapy?
6 Putting it all together AssessmentGives the raw data for theFormulation hypothesesInform theTreatment plan
7 Formulation 1 May also be referred to as ‘conceptualisation’ The formulation aims to supply a psychological explanation of the client’s problemsThe formulation should help to plan treatment - what factors will be targeted?The formulation should be helpful to both therapist and clientThe formulation may also help with treatment decisions
8 Formulation 2 There are different types of formulation, for example: Simple diagram of symptoms and underlying factors (Persons, 1989)Longitudinal map: Early history Schemas, core beliefs Assumptions Triggers Vicious cycle of negative thoughts, emotions and behaviour (J. Beck, 1995; Sanders & Wills, 2005)Full written reports (See Academy of Cognitive Therapy website and Sage website for this book)
9 Formulation 3Notions of formulation are becoming more sophisticated (see Kuyken, in Tarrier, ed., 2006)Need to include social and gender factors and include client strengths as well as problems BUT also need to keep ‘fit for purpose’ – ‘kiss it’ – keep it simple and short!Most importantly, remember that a formulation is only ever provisional. Ideally, keep testing it.
10 Formulation 4Questions for testing formulations (adapted from Kuyken, in Tarrier, ed., 2006)To what extent would/does the client agree with this formulation?Is this formulation more convincing than rival explanations?What significant issues does the formulation not yet explain?Does the formulation fit with other available information?
11 From assessment and formulation to structuring the therapy ON THE ONE HAND – Being comfortable with the structure seems to be one of the distinguishing features of CB therapists or, conversely, discomfort with it may be a distinguishing feature of those who don’t like it or can’t do it (Wills, in Sills, ed., 2006).ON THE OTHER HAND – Structure has different aspects – ‘deep structuring’ guides the therapist in knowing where to go, whereas ‘surface structure’ dictates movement step by step. Deep structure is essential, whereas surface structure can be worn quite lightly – evident in Aaron Beck’s therapeutic style.
12 Session structure (adapted from J. Beck, 1995) 1. Brief update and mood check2. Bridge from previous session3. Collaborative setting of the agenda4. Review of homework5. Main agenda items and periodic summaries6. Setting new homework7. Summary and feedback
13 Structure of session – getting going BRIEF UPDATE AND MOOD CHECK: Very often includes measures such as Beck Depression Inventory (BDI). Some clients may feel discomfort with measures but many will feel pleased that you are taking their symptoms seriously. It is best to regard measures as self-reports subject to some transference effects. Discuss client reservations about them and amend use accordingly.
14 Session structure – moving forward BRIDGING: Ask if client has any memories or issues with the last session. Usually keep brief.AGENDA-SETTING: Work collaboratively: get client’s ideas but also be prepared to put forward ideas yourself. Can use agenda to prioritise and manage time - for example, to ensure time is spent both on current symptoms and on more historical and developmental material.
15 Session structure: getting to the heart of things REVIEW OF HOMEWORK: Don’t forget to do this, as forgetting may reduce client’s motivation to do further tasks. May be helpful for client to keep homework in a ‘therapy notebook’.MAIN AGENDA ITEMS: Some trainees feel like they are being ‘directive’ by encouraging clients to stick to an agenda of items. This may occasionally be true but check out with clients. Padesky & Mooney (1998) suggest that there may be subtle ‘therapist beliefs’ – ‘If I structure the session, the client will experience me as a bully’, etc.!
16 Session structure: ending the session SETTING NEW HOMEWORK: Try to keep it simple and doable. Ask the client, ‘Can you see the purpose of it?’ and ‘What might stop you doing it?’ Try to set NO-LOSE tasks.FEEDBACK: Try to find out what has worked and been learnt and what hasn’t. You need the negative feedback as well as the positive in order to keep the therapy on track