CBT First Few Sessions Notes

Early Sessions in CBT

  • Two primary goals:
    • Socializing Clients to CBT
    • Establishing Strong Rapport

Strategies: Psychoeducation

  • Sharing knowledge.
    • Why use psychoeducation?
    • Normalization
    • Make psychoeducation a conversation

Strategies: Cognitive Restructuring

  • Interpretation of events results in negative feelings and behaviors.
  • Recognition of automatic thoughts allows for opportunities for reinterpretation.
  • Clinicians can use Socratic questioning to inquire as to whether or not there is room for differing interpretations of triggering events.
  • Visual/metaphorical representations can be incredibly helpful for clients.
    • Examples: Thought mapping, Genograms, ABCD flow charts, Subjective Units of Discomfort Scale (SUDS).

Disputation of Automatic Thoughts

  • Clinician’s often have to play the role of the “devil’s advocate” as they teach clients to dispute their automatic thoughts.
    • Client’s need to become their own DA eventually.
    • Example Dispute Questions: What evidence supports that interpretation? What would you think of or say to someone in your same situation? What is so bad about feeling [insert emotion]?

Strategies: Problem Hierarchy

  • Create written list problems on whiteboard.
  • Have client rate each item using SUDS – (0= No Discomfort & 100= Maximum Discomfort).
  • Re-write problems according to SUDS score.
  • Discuss with client – How could this create opportunities for psychoeducation? What could the client learn from this exercise?

Strategies: Homework

  • Homework is essential to the CBT process.
    • Reinforces work completed in session
  • Increases impact of therapy.
  • Often more impactful than session work due to empowerment experienced in implementation.
    • Example: Practicing “I feel” statements vs. thought log

Strategies: In Vivo Exposure

  • Practicing exposure can be essential to cementing new learning.
  • Exposure—an attempt to engage in a moderately anxiety-provoking experience in order to have a concrete example of dispute at work.

Doing the First Exposure

  • Planning for exposure during session
  • Setting up specific, measurable goals for exposure
  • Post-Processing with therapist
  • Homework: Additional Exposure

Client-Related Roadblocks to CBT

  • Clients need:
    • Sense of hope for the future
    • Belief that they will acquire the knowledge and skills they need to lead a healthier life
    • Their concerns to be handled promptly and directly.

My Client doubts CBT will work for Her

  • Explore and understand clients’ concerns
  • Ask client what they understand CBT to be
  • Talk about role of client participation in therapy
  • Use Socratic questioning

My Client Doesn’t Believe He Needs Treatment

  • “Finding the hook”
    • Knowing what clients value is essential to having them buy into therapy

My client believes it is necessary to delve into the past to “get better”

  • Discussion of past allows for richer understanding of core beliefs.
  • Clients benefit from understanding environmental context to dysfunctional beliefs and behaviors

My client thinks his problems are biologically determined

  • Psychoeducation- Nature vs. nurture
    • Cite the research—therapy changes the brain!
    • Therapy reminds clients there can be meaningful life in spite of suffering