Reading G

As mentioned above, CBT is now a very popular form of treatment for a whole range of different psychological problems. The current NICE guidelines (2009) put forward CBT as the psychological treatment of choice for most mental health disorders. It is therefore tempting to think that CBT should be used with every person to solve every problem. Referrers and clients can get quite hopeful about the power of CBT to resolve all difficulties. It is therefore useful to think about certain issues during a CBT assessment and, even better, at the point of making a referral for a CBT assessment. Renaud et al. (2014) note that clinicians who might be concerned about waiting lists and resource implications would be advised to conduct a suitability assessment before commencing CBT.

Safran and Segal (1990a, 1990b) have devised a ‘Suitability for Short-term Cognitive Therapy Interview’ and a corresponding rating scale to help identify those clients who are likely to benefit most from CBT. Although these tools are designed to identify clients who will benefit from short-term therapy, they have also been useful in our clinical practice with clients who require longer-term therapy. There are ten items the authors consider to be important when assessing clients:

• accessibility of automatic thoughts
• awareness and differentiation of emotions
• acceptance of personal responsibility for change
• compatibility with cognitive rationale
• alliance potential: in-session evidence
• alliance potential: out-of-session evidence, including previous therapy
• chronicity of problems
• security operations
• focality
• general optimism regarding therapy.

The above items are each discussed very briefly below, and then we have expanded on the ones we feel are most important later in this chapter.

Accessibility of Automatic Thoughts

Clients need to be able to access their thoughts about situations and events. This can be very difficult for some clients and make take some prompting and education.

Awareness and Differentiation of Emotions

Clients need to be able to recognise emotions and the differences between them.

Acceptance of Personal Responsibility for Change

The degree to which a person identifies their own part in creating their emotional difficulties will often predict how much work they are prepared to put in towards making changes in their lives in order to address their difficulties.

Compatibility with Cognitive Rational

The cognitive model/rationale is described in detail in Chapter 3. However, in brief, the client needs to be able to accept the rationale that our thoughts affect the way we feel and, in turn, the way we behave.

Alliance Potential: In-session Evidence

This is the ability of the client to form a reasonable therapeutic relationship with the therapist.

Alliance Potential: Out-of-session evidence, including previous therapy

This item is about the client’s ability to form positive relationships with other people in general. Clients who have relationship problem with other people are likely to need longer-term therapy.

Chronicity of Problems

The longer the person has been experiencing difficulties, the more sessions they are likely to need in therapy.

Security Operations

This refers to the extent to which the person relies on ‘props’ such as alcohol which may make them feel safer in the short-term but may cause more problems over time.

Focality

Clients who are able to remain focused in sessions are likely to benefit more.

General Optimism Regarding Therapy

Greater optimism about the potential of therapy to bring about change has been shown to affect therapy outcome in a positive way.

During our work in community mental health team settings, we have used the above criteria and, over time, adapted them to suit our needs. This allows us to provide referrers with as much information as possible in order to allow them to make decisions about which clients to refer, without feeling overwhelmed with jargon. The information below can be given, in handout form (see Appendix I), to potential referrers.

The list below gives some pointers to look for during a general assessment to see if referral for a CBT assessment might be relevant. The person doesn’t have to fulfil all the criteria but it does help if they fulfil most of them. On pp. 17-18 are some sample questions to ask clients before making a referral for CBT assessment.

Accessibility and Differentiation of Emotions

• The person needs to be able (even if it takes some prompting) to access negative automatic thoughts, e.g. ‘I messed that up’; ‘People will think I'm odd’.
• It is OK to suggest examples of thoughts that other people sometimes have in these situations, especially if the person is finding it hard to access their own thoughts.
• However, part of CBT is about teaching the client to access thoughts and not all clients may be able to do this to start with.

Awareness and Differentiation of Emotions

• The client needs to be able to gain access to emotions and differentiate between emotions such as guilt, anxiety, sadness, anger, etc. The therapist needs to be aware of differences in language: ‘depressed’ may just mean low in mood to some people. Be aware of cultural differences.
• This is not quite as important as the ability to access negative thoughts and some people may not be able to do this at first. For these people, there may need to be some preliminary work done on accessing emotions before they start CBT (see Chapter 18).

The Client’s Ability to make Use of Therapeutic Input (this is very important)

• An important aspect of therapy is how prepared clients are to make changes in their lives so that they can work on the problems they have. A negative indication might be the question: ‘Have you got a tablet that will make it all go away?’
• How motivated is the client? Are they able to collaborate? Or have they been told, by social services or their partner, to come? If the client needs to be persuaded to start CBT, it is most likely an indication that it is not for them at this time. They can always be referred again in the future.
• The ability to remain focused on the problem in hand may be something that clients have to work towards.

Barriers to Therapy

• If someone is ‘floridly psychotic’. However, a level of psychotic symptoms can be fine, and CBT for psychosis could be considered.
• If someone is in a current manic phase.
• If clients are cognitively impaired, this may make therapy more difficult but not impossible.
• If there are practical issues, or other referrals are being made, the person will need a care coordinator as well.
• If the setting is the NHS, the client will also need to be accepted into the relevant team before therapy assessment can commence.

It is most useful to ask clients to describe situations in which they feel anxious/low/scared, etc. The following questions can then be put.

Accessibility of Automatic Thoughts

When the situation occurred:

• What were you thinking?
• What went through your mind?
• Sometimes people worry that, for example, if they have a panic attack they might faint, or sometimes people might worry that, for example, if they go out, others will stare at them, etc. Do you ever get similar concerns?

Awareness and Differentiation of Emotions

When the situation occurred:

• How did you feel?
• What was happening in your body at the time?
• Ask about different situations and how the person felt at the time.

The Client’s Ability to Make Use of the Therapeutic Input

• What changes would you like to make? (Specific goals are best.)
• What are the advantages and disadvantages of making changes:
  • To the client?
  • To the client’s family?
  • To any other significant others?
• What might get in the way of making changes – attending sessions on a regular basis, etc.?
• Be aware of how focused the client is able to remain on the issue being discussed.