CBT Clinical Handbook, contains CTS-R summary

CBT Clinical Handbook

. 8

CTSR Requirements    2
Agenda    2
Setting the Agenda    2
Using the agenda    2
Feedback    2
Useful questions    3
Collaboration    3
Useful questions    3
Pacing and the efficient use of time    3
Useful questions    3
Interpersonal Effectiveness    4
Useful questions    4
Eliciting Emotions    4
Useful Questions    4
Eliciting key cognitions    4
Useful Questions    5
Eliciting Behaviours    5
Useful questions    5
Guided Discovery    5
Useful questions    5
Conceptual integration    5
Application of change methods    6
Useful questions    6
Homework setting    6
Useful questions    6
CTS-R Check list for sessions    6
General Clinical Work    7
Getting Problem detail    7
Assessment    7
Maintaining Formulations    7
Case Conceptualisation    7
Specific Techniques    8
5 Aspect    8
Thought Records    8
Case conceptualisation    8

CTSR Requirements

Agenda

Setting the Agenda

1.       Collaboratively set the agenda

2.       Up to 2 items

3.       Appropriate

a.       To the stage of therapy

b.      To the formulation

c.       To take therapy forward

4.       Clear and discrete

5.       Do homework review, set homework and do feedback

Using the agenda

1.       As soon as time is up then move onto the next item and if you’re not finished, then ask we can continue on this topic but it would mean that we don’t have as much time to talk about the next item, we could put it on to next week

2.       At the end of an agenda item, say ok, so we have talked about this agenda item, let’s move to the next one

3.       As you move from each agenda item then summarise what’s been talked about

4.       An agenda that is well focussed on the formulation and on the goal, will make peripheral discussion easier to handle

Feedback

1.       There should be two way feedback.

2.       You should get feedback as a review of last week’s session, at the end of every topic and at the end of a session.

3.       At the end of a topic, so can you tell me what you understood from what we have just discussed?

4.       At the end of a session, can you tell me what you understood from today’s session?

5.       Feedback happens every 10 minutes, and the therapist does it by paraphrasing and summarising what has said. You can check the clients understanding at the end of sections.

Chunking is the process of pulling separate pieces of information into larger blocks, so you said both x and y and z, and they all seem to have something in common. Summarising is merely from one block of conversation giving the summarised version of it.

Useful questions

I think I have understood you correctly can I repeat back the main points?

Is there anything that I have said that didn’t make sense?

What was the most\least helpful thing we discussed today?

Can I check I understand that correctly?

Collaboration

Good team work is essential to CBT! The therapist should avoid being too controlling, too active and too intellectual!

Useful questions

1.       So do you think we’ve talked about this enough, if you hit a road block

2.       How might we test that out

3.       That’s a difficult one, let’s put our heads together and work it out

4.       You’ve got your homework for next week, is there anything you’d like me to do

5.       You’re the expert with respect to your problem, could you help me understand

Pacing and the efficient use of time

The therapist should make optimal use of the time in accordance with items set in the agenda. He/she must maintain sufficient control, limit discussion of peripheral issues, interrupt unproductive discussion,  and pace the session appropriately. Nevertheless, the therapist should avoid rushing crucial features of the session. The pacing of the session needs to be according to the needs of the client, you should not overly labour points the client has, nor should you switch topics before a client has a chance to digest.

Basically the session should flow, there shouldn’t be any unhelpful digressions and there should be enough time left for homework!!

1.       Work at clients speed

2.       Have discrete phases, homework review, do therapy, set homework

3.       Therapist can interrupt peripheral discussion

4.       Don’t rush the client

Useful questions

1.       We may have strayed off the topic a little, shall we get back and focus on the chief issues you raised.

2.       Now we have 20 minutes left before the end of the session. Is there anything you think we must cover before the end - keeping in mind that we will also need to set the homework assignment?

3.       Do you think we should move off this topic now?

Interpersonal Effectiveness

You need to have empathy, genuineness and trust. So when a client tells a difficult story, get in there, understand it from their point of view and reflect that back.

1.       Lower levels of warmth can be used towards the end of therapy to encourage disengagement

Useful questions

1.       I understand that X was difficult for you to do

2.       Shared laughter

3.       This must have felt awful for you

4.       You’ve made a great effort here. Thank you.

5.       Despite the huge difficulties, you did really well.

6.       Many people would feel that way, but you have decided to do something about it.

Eliciting Emotions

Therapist needs to elicit or contain the level of emotions. No emotion and the client isn’t engaged, too much and they are distracted. The therapist needs to be able to elicit a range of emotions.  When emotions are present there is a higher degree of reality present, i.e. both propositional and implicational truth, too much you can’t get anything done, no emotion there’s nothing to be done!

Cognitive therapy requires both cognitive and emotional shift.

Useful Questions

1.       You’ve recounted a very sad story but you are smiling how do you understand that

2.       How do you feel telling me that story

3.       You appear to be fearful telling me about that story but I’d like to press you

4.       Do you feel anything else apart from sadness

5.       If you tried to do that how would it make you feel

Eliciting key cognitions

Key methods to achieve this

1.       Questioning, choosing the appropriate method

a.       Socratic questioning

b.      Downward arrowing

c.       5 aspect

d.      DTR

2.       Monitoring

3.       Eliciting thoughts that are related to emotions, i.e. the hot thought

Skill is shown in being able to identify the key thoughts related to the formulation and emotion.

During high emotions then there is likely to be a hot thought.

Drawing out thinking errors of key cognitions can get you brownie points too

Useful Questions

1.       There seems to be a rule you are applying to yourself here

2.       Did you make anything of what happened

3.       What did you say to yourself when that happened

4.       A word that seems to come up quite a lot is weak, is that something you say about yourself

5.       If you don’t finish your work on time what does this say about yourself

Eliciting Behaviours

Behaviour types are withdrawal, avoidance, compulsions and safety behaviours. On some occasions clients might over compensate so become very aggressive when they are feeling weak.  The aim here is to bring out these types of behaviours to the clients attention.

Useful questions

1.       When you felt fear is there anything you did to try to reduce it

2.       If I had a camera when you are feeling low what would I see

3.       Some people develop habits and rituals have you noticed any patterns

Guided Discovery

Guided discovery through questioning should enable a client to develop new perspectives.

Therapist style should be open and inquisitive.

Questioning technique can be from concrete to abstract and back again.

A lateral link is relating a client’s thought or behaviours to current emotional state, a vertical link relates childhood data to current distress.

Good questions are motivated by a spirit of discovery rather than a predetermined outcome

Useful questions

1.       I wonder if there are any other times that you have felt like this

2.       If you were not depressed how would you think about this situation

3.       How does this relate to what you told me earlier

4.       Do you see any link between x and y

Conceptual integration

This includes both the CT rationale and the conceptualisation. It starts with the horizontal formulation of the maintenance, i.e. what is happening now, and then extends vertically to include the genesis of this problem, which includes childhood data, core beliefs etc.

From this then the client needs to establish what they want to work on and the strategies to change.

This is one of the key aspects of therapy, and it is the cornerstone on which interventions happen from.  To show good use of this then it should be used as a platform for interventions, a guide to the agenda and a guide to homework.

The patient should be helped to gain an appreciation of the history, triggers and maintaining features of his/her problem in order to bring about change in the present and future

Application of change methods

Therapist use appropriate intervention in line with the formulation and use the right intervention and the right time both in session and over the course of treatment.  Useful to practice homework in session.

Useful questions

1.       Are there any other events that have happened in your life that can disconfirm this belief

2.       How else could this situation be seen, are there any other alternative views

3.       Have you ever had the same experience in the past and reacted differently

Homework setting

1.       Homework is the bridge between therapy and the real world.

2.       A homework task should have a precise goal

3.       Homework should be derived from what has happened in the session

4.       Homework should be set jointly, obstacles explored

5.       Homework promotes autonomy

6.       You should get feedback from the client, what would they expect to gain out of doing the homework

Useful questions

1.       Does it seem useful

2.       Is it manageable

3.       Is it clear

 CTS-R Check list for sessions

1.       Agenda sessions

a.       Are the items clear and discrete

b.      Are the items going to move therapy forward

2.       Feedback

a.       Is there 2 way feedback

b.      Is there regular feedback

3.       Collaboration

a.       Is there evidence of teamwork

4.       Pacing and the effective use of time

a.       Work at clients speed

b.      Interrupt peripheral discussions

5.       Interpersonal effectiveness

a.       Are the core cognitions present

6.       Eliciting emotions

a.       Is emotion elicited or contained, enough to do effective work

7.       Eliciting key cognitions

a.       Are key cognitions related to formulation elicited

8.       Eliciting behaviours

a.       Are behaviours related to formulation elicited

9.       Guided discovery

a.       Is there evidence of guided discovery

10.   Conceptual integration

a.       Is there a formulation using vertical and horizontal aspects at work

b.      Does it help the client appreciate their problem

11.   Application of change methods

a.       Is there a clear rationale for change methods

12.   Homework setting

a.       Do I explain the benefit of homework

b.      Does the client understand the benefit to them for the homework

General Clinical Work

Getting Problem detail

1.       How do you know you have a problem

2.       What makes it  a problem

3.       Modulators

4.       Intensity and duration

5.       When does it happen

6.       With Whom

7.       Where

Assessment

Psychoeducate in CBT, do CBT as learned behaviour and use the physiotherapy analogy

Maintaining Formulations

These can be

1.       5 aspect

2.       Functional Analysis

3.       Vicious flower

Case Conceptualisation

Self Esteem=Fennell

Depression=Judith Beck

Anxiety=Wells

Specific Techniques

5 Aspect

1.       When doing this, you can start with one situation and its behaviours, emotions etc. Then as this leads to another behaviour, then do another set, so you can have a spiral.

2.       You can do a 5 aspect and ask the client what they see, any relations. You can also ask the client where the best place they think to break into the cycle would be.

3.       You can also ask what the consequence of this cycle is.

4.       Look at the different types of thoughts that come up, rules, core beliefs and NATs

Thought Records

1.       If a client is just starting on these only fill out the first three columns

2.       When they put down multiple thoughts select the hot one to dispute

3.       When looking for alternative thoughts then ask what would a good friend say about this if they looked at it, or what would you say to someone else in this situation

4.       Rate the emotions and the beliefs as they pay off is in the balanced thought reducing these

5.       When we are depressed, or anxious we tend to only focus on the evidence that supports our thoughts, our minds operate like spotlights and only see things in the light not all around

6.       Certain thoughts appear truer dependent on how you are feeling

7.       Make sure you fully describe the situation this will be very significant in eliciting the thoughts

8.       When you get the NATs consider drilling down on them after you have collected and want to identify the hot thought

9.       With the evidence that supports the hot thought, make sure you get evidence, if someone says I’m fussy, how do you know, who says

10.   Rate the hot thoughts belief and the emotion

Case conceptualisation

1.       Useful to get longitudinal analysis. So is there anything that you’ve experienced through your life that is relevant to these issue?  Hmm maybe that needs more thought, when Padesky did it she was looking at career and being a mum, so she asked when you were growing up is there anything you experienced that is relevant to these issues.

2.       When you find a core belief find out how it has served the person, then find out how it hasn’t

3.       When you look at rules and beliefs then ask if there are other rules that you would want to work to, to achieve what you want