CBT assessment - Bristol CBT

What to expect from a CBT assessment: A guide for individual clients

Before we decide to start treatment, we need to get a good idea of what problems you’re experiencing, how severe they are, and how they’re affecting you and your life. We also need to develop a working hypothesis about the origins of the problem and what’s maintaining it. This process is known as assessment and formulation.

Assessment is a process that usually takes one or two sessions. It is a conversation where I can find out more about the difficulties you’re dealing with, and you get a chance to find out whether you think I could be helpful to you. Every assessment is individualised, and every therapist works in somewhat different ways. I tend to follow a semi-structured format that covers several areas in detail. Before our first session I will ask you to complete a set of standard CBT questionnaires and to send me the results. Other than that, you don’t need to prepare anything for our first session. The topics I’ll ask you about can be broken down into nine sections.

What is the problem?

I’d like to get an idea of what you’re finding most troubling or difficult, so I will ask you to tell me, in a nutshell, what the main problem is that you’re seeking help for.

I’ll then ask you what prompted you to make contact. For example, has there been a specific incident, or were you encouraged to come by someone else, or is it perhaps that things have been building up and now feel too much for you to manage on your own?

Sometimes when people make the decision to seek help it motivates them to make some changes even before the session. I’ll also ask you’ve already done to help deal with the problem since you decided to get in touch.

Some problems are longstanding, while some are more recent, and others might come and go over time. I’d like to know when this problem started, how long it’s been going, how it’s changed over time, and whether it feels as though it’s getting better, worse, or fluctuating. I’d also like us to discuss whether you’ve had this problem before and, if so, how you dealt with it.

It will be helpful to know what the main symptoms are that you are struggling with. We’ll discuss your scores on the set of standard questionnaires on low mood, anxiety, phobias, and the impact of the problems. Your answers will help us to understand whether you have a mental health problem, such as depression, and if so, how severe it is. Regularly completing these questionnaires, if you choose to do so, will help you see the progress you’re making.

In addition to the questionnaires, I’d also like to ask you about symptoms in four different areas:

The physical self: I’d like to know whether you’ve noticed changes in sleep, appetite, fatigue, concentration, motivation, and interest in sex. I’d also like to know whether you’re experiencing any pain or unpleasant physical sensations or have a medical condition that needs managing.
The emotional self: I’d like to know about your mood, that is, how you have been feeling on most days for most of the day. I’ll also ask how you tend to respond emotionally to events.
The cognitive self: cognition refers to our thinking processes, such as worry and rumination, and to the content of our thoughts, such as thinking we are worthless or a failure, or believing that we are not good enough. I’d like to ask whether you’ve noticed any changes about your thought processes, for example having intrusive thoughts or memories, and how you have been thinking about yourself, the world, the past, and your future.
The behavioural self: usually people have tried to find ways to cope with their difficulties, so it will be helpful to know what coping strategies you’ve tried, what’s been helpful, and what might be unhelpful, such as avoidance or over-reacting. I’ll ask whether you’ve stopped or recently restarted any activities and if so, why.

Symptoms can fluctuate depending on the time of day, week, or month, whether you’re on your own or with other people, and whether you’re in a specific setting such as at home, socialising, or at work. I’d like to ask you about the when, where, and with whom of your difficulties. Understanding specific, time-limited problems, such as panic attacks and flashbacks can be assessed according to the situations that trigger them (if known) and their frequency, intensity, unpleasantness, and duration.

You wouldn’t be seeking help if your difficulties weren’t affecting your life and how you feel. I’d like to ask you what impact these difficulties are having on different areas of your life such as work, self-care, home management, family and relationships, socialising, and your hobbies and interests.

Coming to see me might be the first time you have reached out for help, or you might have tried, or are having, other treatment. I’ll ask whether you have ever seen a mental health professional (such as a counsellor, therapist, psychologist, or psychiatrist), how helpful you found it, and what you took away from it that was useful, if anything.

While people often come to therapy with a main problem they might also be struggling with other difficulties. It might not be something you want help with right now, but it would be useful to acknowledge it and understand how it affects you.

Sometimes people have coped with life well before this specific difficulty started. On other occasions people might have a long history of struggling to cope. I’d like to know how you were doing in your life in general before this problem started to affect you.

We know that mental health problems often run in families. I’d like to ask you whether you’re aware of any close family members or relatives that have struggled with their mental health and what effect, if any, that has had on you.

Finally, I’d like to get a sense of what you think might be going on, that is, what your theory is about why you’re having this problem at this time.

Substance use

I’d like to understand the impact of the various substances you currently use, or have previously used, so I will ask you about both what substances you take, how often, in what quantities, and with what effects, and whether they are helpful or potentially harmful. These include:

Caffeine: such as coffee, tea, and energy drinks
Nicotine: such as cigarettes and other tobacco products as well as vaping
Alcohol: such as beer, wine, cider, and spirits
Recreational drugs: such as cannabis, cocaine, MDMA, and ketamine
Prescribed medication: for physical health problems, such as insulin for diabetes, and for mental health, such as antidepressants or anti-anxiety medications
Non-prescription medication: such as over-the-counter supplements or herbal remedies

I don’t assume that any of the above will be a problem. However, it is useful to know whether substance use or potentially compulsive behaviours, such as excessive gambling or pornography use, have had an impact on work or study, self-care, relationships, or led to legal problems.

Risk

Sometimes people might be at risk or might tell me that others are at risk. I would like to understand whether this is true for you so that we work together to help keep you or another person safe.

Suicidal thoughts: suicidal thoughts are very common. I would like to know whether you are having thoughts that you would be better off dead or of harming yourself in some way. If you have, I’d like to understand whether you have made any plans or taken any steps towards ending your life. I would also like to know if this has been true in the past and with what consequences.
Self-harm: sometimes people have thoughts of hurting themselves or are engaging in self-harming behaviours, usually in response to deep psychological pain, or from feeling dissociated and numb. My goal is to work with people to reduce the risk to themselves through developing coping strategies that can help manage pain more constructively.
Harm to others: sometimes people have trouble managing anger and aggressive impulses. If that is true for you then I would like us to discuss how to help you manage those feelings so that you are safe and you don’t put anyone else at risk.
Harm from others: sometimes a person might feel at risk from another person, for example a current or ex-partner. If that is true for you then I would like to discuss how we can help keep you safe.
Safeguarding: if you have dependents or a caring responsibility to a child or a vulnerable adult, then it would be helpful to discuss whether there is any reason to be concerned for their wellbeing, and if so, how we can work to ensure their safety.

Life situation and you as a person

I would like to understand the stresses and supports in your life and how they affect you, and rather than make any assumptions about you, ask you about the way you describe yourself:

Work/study: what is your current occupation or area of study, if relevant, and how are you finding it?
Housing: what is your housing situation and how secure or satisfactory is it?
Relationship: what is your relationship status and how do you feel about it?
Family: what is your relationship like with your immediate family and how does that make you feel?
Friends: what is your circle of friends like, and how supportive do you find them?
Financial: how secure is your financial situation and are you struggling with debt or the cost of living?
Grief (loss): what bereavements have you experienced and how do they continue to affect you, if at all?
Disputes/disagreements: are you experiencing any conflict with anyone and, if so, how is that affecting you?
Life changes: have you had any major life changes or changes in role recently and, if so, what impact has that had?
Loneliness/social isolation: are you feeling isolated, lonely, or unsupported and, if so, how is that affecting you?
Interests: what interests or hobbies do you have and how well are you able to engage in them?
Spirituality: do you have a faith or are you part of a faith community and how well does that support you?
Ethnicity/culture: how do you describe your ethnicity and/or culture and how is that relevant to your current difficulties, if at all?
Sexual orientation/gender identity: how do you describe your sexual orientation and gender identity, and how is that relevant to your current difficulties, if at all?

Personal history

As well as understanding you as you are now it is also helpful to see your difficulties in the context of your personal history.

Family of origin: who were you raised by and in what sort of family structure?
Childhood and adolescence: overall, how would you describe your formative years and their impact on you?
Education: what was your experience of education like in primary school, secondary school, college, or university, if applicable?
Developmental challenges: were you diagnosed with, or did you receive any help for, any developmental difficulties such as autism, ADHD, dyslexia, and dyspraxia
Medical history: what medical procedures have you had when you were younger, for example illnesses or hospital stays as a child, and what was that experience like for you?
Adverse childhood events: have you ever experienced abuse or neglect and what impact has it had on you?
Adulthood: how have your adult years been, in general?
Occupational history: how has the working world been for you to date?
Criminal or legal problems: have you ever had any dealings with the criminal justice system or been convicted of an offence, and how has that affected you?

Goals for treatment

I would like to ask you what you’d like to get out of our sessions together, so will explore the following questions:

If this treatment were to be helpful, what would you like to be able to say has changed for you?
What makes those goals important?
What do you think needs to happen to achieve those goals?
How do you feel about what treatment might involve?

Feedback

Having discussed the previous topics, I would like to get some feedback on our conversation. I would particularly like to know whether it went as you expected, whether at any point there was something that I didn’t seem to understand, or whether you didn’t like the way I responded to you. I’d also like to hear whether there’s anything else that you think it is important for me to know.

Contract

I’d like to ask you whether you think that this treatment could be helpful for you, and I will also share my opinion about whether I think I have the right blend of experience and skills to be helpful. If we agree to proceed, we can discuss how often we meet and when.

Home practice:

Therapy is most effective when you can take the learning from our sessions back into your life and practise what we’ve discussed. If we agree to work together, I will discuss an exercise, or suggest some resources, that I think you might find helpful and check whether you’d be happy to try those yourself.

In summary, the assessment process is our chance to find out more about what’s going on, and whether there is a good chance that I can be helpful to you. At the end of the process, neither of us is committed to starting treatment. If it has gone well, you feel understood, and my working style appeals to you, then we will probably want to book some further sessions where we can set some goals and come up with a plan to help you achieve them.