The First CBT Sessions What does an initial

The First CBT Sessions What does an initial session with a client look like in CBT? How do you orient your client to CBT? What are some common structural elements across CBT sessions?

The First CBT Session: Elements Common Across Therapies § Assessment: Symptoms, risk, behavior, suicide and homicide risk, psychosis, substance use, etc… § History: Psychiatric, family, relationships § Evaluation of symptoms associated with presenting problem (current and past) § Understanding clients’ values and goals

Values Worksheet Disorder Value Goal Linking Desired Mechanism Treatment Outcome Depression Having friends This week, call a friend who you haven’t spoken to in a while and catch up Build social support and enhance relationships with significant others Reduce depressive symptomology Anxiety Being selfconfident This week, try to notice moments of success and write these moments down Challenge Reduce anxious negatively skewed symptomology self-image by highlighting moments of mastery and success

The First CBT Session: Elements Specific to CBT § Behavioral assessment of problem behavior: functional analyses (also known as behavioral chain analyses, ABCs) § Use of psychometrically validated self-report measures § Orientation to CBT

Behavioral “Chain” Analyses For a sample chain analysis to use with your clients, see the Worksheets section in the Resources module

Change in CBT Thoughts Feelings Behaviors Physiology

An example: Thought: I won’t be able to go to the mall Behavior: Avoidance Procrastination Feeling State: Anxiety Fear Physiology: Limbic system (e. g. , amygdala) Endocrine (e. g. , cortisol) Autonomic (e. g. , sweating)

Vulnerability Factors Inside the Skin Outside the Skin Antecedents Behavioral Problem Consequences

Vulnerability Factors • • Tired Physically ill Meds not taken Pain Antecedents Behavioral Consequences Problem • • Thoughts Emotions Sensations Memories Inside the Skin • • • Outside the Skin • • • Stressful events Nighttime Unpredictabl e situation • People • Places • Things Fear, anxiety, shame, anger action urges Increased physical pain Problemati c beliefs • Freeze • Fight • Flight • • Temporary relief of shame, anger, etc. Feel out of control Feel incapable Feel victimized • Harm to self • Harm to others • Do not learn

Use of Self-Report Measures § Rationale: Allows you to assess your clients’ baseline levels of dysfunction and track progress over time (for examples of commonly used self-report measures, see Validated Measures of Psychopathology in the Resources module) § Functions − Assess severity of psychopathology − Assess symptomology of particular disorders − Monitor current activities, thoughts, moods to find patterns − Identify values and goals for treatment

Orientation to CBT: ADD SOME HOPE Assess treatment history and compare to CBT Describe body of evidence to support CBT Detail the expected session process and outcomes

Orientation to CBT: ADD SOME HOPE Start the behavioral assessment Outline connection between thoughts, emotions, & problem behaviors Model being skillful when clearly relevant Explore patient expectations about CBT

Orientation to CBT: ADD SOME HOPE Help client/patient link values & goals to treatment outcomes Obtain a commitment to treatment Plan for out-of-session changes Emphasize need to measure outcomes

Boiling it down, CBT therapists should remember their Cs § Consideration of context § Collaboration § Compassion

Session Process in CBT: Common Principles § Observe non-judgmentally § Validate carefully § Validate the valid, and ignore or invalidate the invalid § Be aware of your responses to emotion § Respond contingently, if needed § Explore automatic thoughts linked to emotion § Use emotion to engineer new behavior § Don’t talk about doing it, do it!

Session Process in CBT: Common Elements § Review therapy homework § Identify specific target(s) for session § Behavioral assessment (again and again) § Case conceptualization guides hypotheses § Identify context of problem behavior § Introduce a skill (e. g. , approach behavior, cognitive reappraisal, etc. ) § Practice the skill § Troubleshoot how and in what context to use the skill § Refine plan for use of skill in context § Obtain commitment for skill use