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CONCLUSION • Thank. • Check the client’s agreement to the suitability decision. • Check client’s agreement with further action plan (e.g. write to the GP/referrer, make further referral, make another appointment for continuing the assessment, set homework etc.) • Ask whether there is anything else the client wants to add or ask.

Cognitive Behavioural Therapy Assessment

Overview Of The Issue Overall picture of the symptoms and distressing experiences, highlight the triggers and feared consequence

What: What is happening at the moment that concerns you? What issue would you like to work with?

Where: Where is it likely to happen more/less? Is it worse in familiar/unfamiliar surroundings?

With Whom: With whom is it better or worse? E.g.: family, friends, crowds, strangers?

When: When is it likely to happen more/less? Does it get worse in the mornings/ evenings?

Feared Consequence/Belief: What is the worse thing you fear would happen if you did/did not…? What is the worst thing for you about having this problem?

Behaviours Identifying the coping mechanisms and safety behaviours

Behavioural Excesses: What do you (do, think, say to yourself) to make you feel better? Are there things that other people do for you that make you feel better?

Behavioural Deficits: What do you do less of to make you feel better? What have you stopped doing? Anything you do less of due to the issue?

Details of Issue

Frequency: (occurrence of issue) How often in a week/day/hour do you? Longest, shortest, typical, last?

Intensity: 0-8 Scale, How far would you go before needing to use safety behaviour?

Number: (occurrence of behaviour in relation to issue)

Duration: How long does …. last for?

History Of Issue

Onset: When did the issue start? (the most current episode) When were you last well? Why is it worse now?

Precipitants: What circumstances change the problem? Can you identify any triggers?

Fluctuations and Modifiers: How have your symptoms changed over time? Have there been times when you are well or you suffer more?

Previous Treatments: In the past have you received any medication/therapy for the issue? Have they been effective or beneficial?

Psychiatric History: Have you ever been in contact with mental health services in the past for any other issues?

Hospital Admissions: Have you ever been admitted to a psychiatric hospital?

Self-help Methods: Have you read any books, tried alternative therapies, used helplines in regards to the issue?

Other: Is there anything else you do that helps/makes the issue worse that we have not yet discussed?

Recent Incident Analysis

Description Of The Incident: Describe a recent example of the issue, which is vivid for you, that you can take me through

| |Autonomic: What was the first thing you noticed happening with your body just before the incident? |
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|Antecedents: | |
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| |Behavioural: What were you doing just before the incident? |
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| |Cognitive: What was going through your mind just before the incident? |
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| |Autonomic: What was happening with your body when the incident was occurring? |
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| |Behavioural: What were you doing during the incident? |
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| |Cognitive: What was going through your mind during the incident? |
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| |Autonomic: What was happening with your body after the incident occurred? |
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|Consequences: | |
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| |Behavioural: What did you do after the incident? |
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| |Cognitive: What was going through your mind after the incident? |
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Impact On Life (needs to be specific and in relation to the issue)

Work: Are you still working, if so in what area? Has the issue effected your work or aspirations?

Social Activities: Has your social life changed as a result of the issue?

Activities Of Daily Living: Has the way you manage your home changed as a result of the issue? What do you do around the house?

Leisure/Hobbies: Have you stopped doing activities that you once enjoyed? Have you started any activities as a result of the issue?

Relationships: Are you in a current relationship? Has the issue effected your relationships or your ability to form relationships?

Distress: What’s the worst thing about being this way/having this issue? If no distress – why is this a problem for you?

Substance Use (identify if the following are used as coping mechanisms for the issue in question)

Alcohol: What sort? How much? What strength? What time of day? Why do you use it? Does it help with your symptoms? Any intention to reduce or stop?

Illegal Drugs: What sort? How much? What strength? What time of day? Why do you use it? Does it help with your symptoms? Any intention to reduce or stop?

Prescribed Medication: What sort? How much? What strength? What time of day? Why do you use it? Does it help with your symptoms? Any intention to reduce or stop?

Unprescribed Medication: What sort? How much? What strength? What time of day? Why do you use it? Does it help with your symptoms? Any intention to reduce or stop?

Tobacco: How much? What strength? What time of day? Why do you use it? Does it help with your symptoms? Any intention to reduce or stop?

Caffeine: How much? What time of day? Why do you use it? Does it help with your symptoms? Any intention to reduce or stop?

Physical Health

Neurological: Do you suffer from headaches? Migraines? Epilepsy? Fainting? Blurred vision? Strokes? Have you had any operations regarding your head?

Cardiac: Have you any problems with your heart? Do you get chest pains? Have you any operations regarding your heart?

Respiratory: Have you any problems with your chest or your breathing? Have you got asthma? Have you had any operations in this area?

Gastrointestinal: Have you any problems with your stomach or bowel? Do you suffer from constipation, diarrhoea?

Other: Are there any physical conditions that I should be aware of?

Brief Mental State Examination

Appearance/behaviour/attitude: Weight, dress, hygiene, speech, gait, activity, anxiety symptoms, cooperative, evasive, hostile.

Mood: Are there occasions when you have felt very low, sad, down, high? How many good/bad days in last week?

Energy: Have your activities changed in the last month? What do you normally do in a day? Do you feel more tired than usual?

Interest/Pleasure: For the activities that you are doing do you still enjoy them?

Sleep: How many hours sleep do you get on average? What time do you go to bed? What time do you wake up? Do you sleep all the way through? Is it hard to fall asleep? Do you have nightmares?

Appetite: How may meals a day? Do you enjoy your food? Have you lost/gained weight? Are you worried about your weight? Bingeing/vomiting/laxative use?

Concentration: Do you get easily distracted? Can you read a book/watch TV for half an hour or more?

Memory: Have you noticed losing, misplacing things more recently? Do you get lost in public?

Orientation: Time, Place, Person?

Irritability: Are you angered easily? Do you lose your temper? Have you been more snappy? Have you acted on it towards people or objects? (If yes complete risk assessment for violence on next page)

Unusual Experiences: Have you seen/heard things that others could not see? Have you had experiences that are unusual for you? Have you been so anxious that it feels like you have left your body?

Risk Assessment

Suicide

Current Thoughts: Do you ever think of ending it all? If so how often?

Current Plan: If you were going to harm yourself how would you do it? Have you collected any information? Would anyone find you?

Current Intent: Have you a date and time in mind?

Current Opportunity: Have you any equipment that may help you kill yourself self?

Preventative Factors: What would stop you from killing yourself? Have you any beliefs that disagree with suicide?

Hope For The Future: What do you think you will be doing in six months time? Have you any plans for next week/tomorrow?

Support: What networks have you in place that would support you?

Past Attempts: Have you ever tried to kill yourself? Are you happy that you were unsuccessful?

Violence

(put here information from the Irritability question from the mental state examination)

Current Thoughts: Do you have violent thoughts, fantasies or urges?

Current Behaviours: Do you have a problem controlling your temper?

Current Opportunity: Do you have access to or carry weapons such as knives?

Support: Have you networks in place that would stop you becoming violent?

Past History: Have you ever been violent to anyone else? Have you been in trouble with the police in regards to violence?

Motivation & Commitment

Change? Do you think that you are ready to start making any changes in your life? Or are you ready to talk about making changes?

Commitment: Will other current life events cause you not to be able to focus on this treatment? Will you get support from family or friends?

Outcome

Name:

Date(s) of Assessment:

Contact details:

EXPLANATION OF CBT • A framework for understanding a problem by identifying how certain ways of thinking and behaving maintain the problem here and now, not interpreting past events. (formulation) • A set of treatment methods and techniques to improve symptoms or our coping with them, by unlearning unhelpful thinking patterns and behaviours, and learning/reinforcing more helpful ones. (treatment rationale) • The learning process is done with the client rather than as a “therapy” done to them. The therapist offers his/her expertise in cognitive-behavioural methods but the client is the expert in applying these methods to their own problems. (collaborative empiricism) • It is a doing rather than a talking treatment; it requires setting the treatment as a priority and carrying out “homework”. (homework)

Genogram

Expectations & Goals

What do you expect to get out of this therapy? What would you like to be able to do in the near future that you can’t do now because of the issue in question?

Relationships:

Family dynamics

Past serious relationships

Social network

Plans?

Sexual history:

Any difficulties during puberty?

Any distressing sexual experiences?

Sexually active?

Any problems?

Spiritual beliefs:

Brought up with religion?

Currently practice?

Problems & Goals (optional)

Definition of problem:

I feel ______________ about ________________ and this leads me to _____________. I have stopped __________and have started ___________This has been a problem for ___months/years.

On the scale below please rate how much your problem upsets you and/or interferes with your normal activities:

0 1 2 3 4 5 6 7 8 does not slightly/ definitely/ severely/ extremely/ sometimes often very often continuously

Definition of Goal:

I would like to be able to _______________ under the following conditions / without _____________. I would like to do this for ___ mins/hours. A __% reduction in ________ would indicate success.

On the scale below please rate how difficult it would be if you had to achieve this goal now:

0 1 2 3 4 5 6 7 8 not at all slightly moderately very much extremely

Employment:

Current jobs?

Previous jobs?

How many?

Reasons for leaving?

Childhood:

Where born?

Any complications in birth?

Developmental stages?

Home atmosphere?

Relationship with parents?

1. Before meeting the client: • Read the referral letter and any other relevant documentation. • You may choose not to take any documentation (previous notes or referral letter) in session with you, so make a note of the main points. • Perhaps you would find useful to prepare a general sheet (or index cards) with a structured screening interview guide (headings and prompt questions) and make a note of any specific information you need to find out for the particular client.
2. On meeting the client: • Introduce self by stating your name, professional title and role. • Ask permission if other people need to be present or observe the interview, introduce them and explain their role, e.g. research, training, supervision, etc. • Established client’s preferred name. • Ask permission if the interview needs to be taped, explain and sign a consent form. Keep a copy of the signed consent form and give a copy to the client. • If the interview is taped, point out the camera/tape recorder. • Confidentiality: explain who you may share information with and in what form (team meetings, letter to GP, supervision, etc). If client does not want anyone else involved in their care (family, GP, etc) to know details of their treatment, then explain the conditions under which you are allowed to breach confidentiality.
3. Starting the interview: • Explain the purpose and time-scale of the interview. • Mention what you already know from other documentation. • Set the agenda COLLABORATIVELY (what you will cover in your interview and in what order). • Ask the client whether they have anything else to add or ask before you start the interview. • Explain that you may be taking notes during the interview and the reason for it.

Education:

School years?

Trusting?

Friends?

Bullying?

Qualifications?

Personal History