The Evaluation Session in Cognitive Behavior Therapy

Goals and Structure for the Evaluation Session

• Learn to conduct the patient assessment and relationship between tentative diagnosis and treatment planning.
• Understand how to establish treatment goals and manage patient expectations.
• Develop a cognitive conceptualization of the patient following the evaluation session.

Importance of Thorough Evaluation

• Effective cognitive behavior therapy (CBT) relies on a comprehensive patient evaluation.
  • Accurate case formulation
  • Individualized treatment plan based on patient's presenting problems, functioning, symptoms, and history.
• Supplement evaluations from previous clinicians with additional data collection.
• Need for ongoing assessment to confirm or revise diagnoses throughout treatment.

Goals of the Assessment Session

• Besides diagnosing, the assessment helps to:
  • Formulate the case and initial cognitive conceptualization.
  • Determine therapist-patient appropriateness and assess treatment capacity.
  • Identify whether adjunctive treatments (e.g., medication) are needed.
  • Establish a therapeutic alliance with the patient and relevant family members.
  • Socialize the patient into therapy's structure and process.
  • Identify crucial problems and broad treatment goals.

Strategies for Efficient Evaluation

• Gather as much information before first contact:
  • Request reports from previous clinicians and have patients complete self-report questionnaires if possible.
  • Ensure patients have had recent medical checkups to rule out organic problems (e.g., hypothyroidism mistaken for depression).
  • Encourage support from family or friends during the session to enhance information sharing.

Structure of the Assessment Session

1. Greeting and Initial Interaction: Engage the patient and decide on the presence of family members during the session.
2. Set the Agenda: Clearly communicate what will be covered in the session, including questions on symptoms, history, and setting broad treatment goals.
3. Conduct Assessment: Collect detailed patient information, covering demographics, complaints, history, coping strategies, psychiatric history, substance use, medical history, and family history.

Key Information Areas to Address

• Demographics, chief complaints, history of present illness, coping strategies, psychiatric history, substance use, medical history, family psychiatric history, social history, educational and vocational history, religious/spiritual history, and personal strengths.

Assessing Daily Functioning

• Gain insight by understanding the patient's daily routine:
  • Variations in mood and interaction with others.
  • Overall functioning in different environments (home, work, school).
  • Activities they engage in or avoid, helping to identify treatment targets.

Probing for Critical Data

• Structure patient responses to acquire relevant information:
  • Ask direct, confirming questions to clarify understanding and gather needed data.
  • Essential to be alert for indications of patient ambivalence towards treatment.

Finalizing the Assessment

• At the end of the assessment session:
  • Ask if there's anything else important to know, including reluctance to disclose information.
  • Involve family members if present, ensuring communication aligns with patient comfort.

Relaying Impressions and Setting Goals

• Present initial impressions and tentative diagnosis to the patient and outline treatment expectations:
  • Set clear, realistic goals that guide treatment focus, such as reducing anxiety, improving academic performance, and rebuilding social connections.

Developing an Initial Treatment Plan

• Synthesize evaluation insights to create a cognitive conceptualization, understanding:
  • Development and implications of negative core beliefs and automatic thoughts on the patient's emotional state and behavior.
  • Create treatment strategies to address academic challenges, social interaction, and cognitive restructuring.

Maintaining Flexibility and Involvement

• Reassess the treatment plan and treatment efficacy regularly:
  • Emphasize patient involvement in decision-making to enhance motivation and compliance.