CBT notes with additional session request example

 

Authors:	Angela Jones (Senior CBT Therapist)
Date:	16/07/2024

 

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Yes

×

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Treatment Session Notes

Patient First Name: James

Patients Last Name: Smith

Date of Session: 22/05/2024

Session Number: 9

Treating Clinician: A Therapist

Treatment Type:  CBT

Treatment Modality: * CBT

Current Pathway: * In Treatment

Current Work Status: * Full duties

Primary Working Diagnosis/Primary Presentation: * Depression

 

Agenda: *

 

-            MDS review

-            Risk review.

-            Review of home task

-            Continue behavioural experiments.

-            Set home task.

-            Feedback on session.

 

Review In-between session:

 

Last session James identified a rule for living that has a significant impact on his day-to-day life:

“If I make a mistake then people will think badly of me”.

 

We then set a home task form James to look at changing this into a guideline – please see uploaded documents for a thorough overview of the process worked through.

 

James was able to develop the guideline:

 

“If I make a mistake whilst it’s not ideal, people will not necessarily think badly of me, I am only human”. 

We spent time reflecting on this guideline and James could see that this would be beneficial for him to live by, he said for example that it would take some pressure off him at work which would help him gain a better work/life balance.

 

Content of Session: *

 

MDS review: James’s scores on the PHQ9 and GAD7 have remained the same since last session. We explored this further, and this appears to be an accurate reflection.  Overall, his scores have reduced from severe to moderate on both the PHQ9 and GAD7.

 

Today’s session was spent considering behavioural experiments that could be used to test out the new guideline (as generated for his home task). Please see the uploaded document for a full overview of the experiment we designed, and James’s predictions. 

 

We reflected on the experiment that we designed (for James to make a spelling mistake in a work email), James felt anxious (75%) at the thought of doing this, but he was able to acknowledge the benefits of doing so.

We then considered this new guideline in the context of his initial formulation. James was able to identify that his initial rule (“If I make a mistake then people will think badly of me”) was linked to his core belief “I’m a failure”, James felt that through the work we have done to date this core belief has lessened in its intensity (100% belief at assessment to 65% today) and he hopes that acknowledging this reduction will give him “some confidence” in testing the new guideline out.

 

Session feedback: James reported feeling “anxious” at the thought of carrying out his behavioural experiment, but he said that he is “determined” to work towards his goals and acknowledges this as a step towards these. 

 

Treatment Plan:

 

We are using Becks cognitive model of depression.

 

We have completed thought psycho-education, thought challenging, rules for living and core belief-based work. We are now incorporating behavioural experiments to test out new rules/beliefs.

 

James asked if he would be able to have any more sessions, as he felt that whilst he has made progress, there is still scope for more improvements to be made. We discussed the process for requesting additional sessions and I advised him that they can’t be guaranteed. Agreed to request 5 more sessions – please see request below.  

 

Risk Assessment

Please do not use N/A. Please indicate that you have explored this with your client and document their response.

Suicidal Thoughts: *

 

James scored 0 on PHQ9 Q9. We discussed this further, and James confirmed that he had no suicidal or self-harm thoughts and he felt able to keep himself safe.

 

Current Plan: *

 

James confirmed he had no plans to harm himself or end his life.

 

Access to Means: *

 

James confirmed that he had not made any preparations or gathered any means by which to harm himself or end his life.

 

Intent Rating: *

 

James confirmed he had no thoughts and intent is low.

 

Self-harm Thoughts: *

 

James confirmed he had no self-harm thoughts since our last session.

 

History: *

 

James has disclosed one historic suicide attempt – please see initial assessment for full details.

 

Risk Factors: *

 

There has been no change in risk factors (please see initial assessment for full details)

 

Current Triggers: *

 

Triggers remain the same as at initial assessment (work-based stress).

 

Safeguarding Issues: *

 

There are no current safeguarding concerns.

 

Protective Factors: *

 

James confirmed that his children and his wife remain his protective factors.

 

Risk Management and Safety Plan: *

 

James has confirmed if anything was to change he would reach out to his GP, or NHS 111 (if out if hours).

 

James has been provided with a safety plan which has been uploaded to his file as an attachment. The safety plan also contains contact details for services such as the Samaritans.

 

Risk Formulation: *

 

James presents with one historic suicide attempt (please see initial assessment for further details), this was triggered by several bereavements in a short space of time.

 

Since this time (7 years ago), James reported he has much hope for the future, especially since he has got married and had children.

 

James reported not currently experiencing any suicidal thoughts or thoughts to self-harm. He stated that he would reach out to professional services if these thoughts were to re-occur.

 

Risk Rating: *

Low

Does this clients risk presentation require review by VHG Risk Duty?: *

No

 

If yes Rationale for risk review: *

N/A

Clinician Requests

Please use this section to complete any additional sessions requests or request for clinical review.

Do you need to request additional sessions: *

Yes

If yes Rationale for additional sessions: *

 

To date James has completed 9 of 12 sessions, please can we request an additional 5 sessions.

 

We are using a Beck formulation to support James with his symptoms of depression, James has engaged well and shown good motivation throughout therapy. Despite this his scores on the PHQ9 and GAD7 remain in the moderate range due to entrenched rules for living and core beliefs.

 

We are currently conducting behavioural experiments to support the development of new rules and beliefs, however we would benefit from additional sessions to work on this due to the longevity of symptoms.

The 5 additional sessions would allow time to continue behavioural experiments in order to strengthen new rules for living and core beliefs, we would also complete a robust relapse prevention plan.

 

 

Request clinical review of case by VHG clinical team?: *

No

×

If yes Reason for clinical review: *