CBT notes with risk review example
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Authors:
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Angela
Jones and Jen Clue (Senior CBT Therapists)
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Date:
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20/08/2025
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Treatment Session Notes
Patient First Name: James
Patients Last Name: Smith
Date of Session: 22/05/2024
Session Number: 4
Treating Clinician: A
Therapist
Treatment Type: CBT
Treatment Modality: CBT
If cCBT please enter Silvercloud ID: ID number or N/A
Current Pathway: In Treatment
Current Work Status: Full
duties
Primary Working Diagnosis/Primary
Presentation: Depression
Agenda/Session
focus:
· MDS review
· Risk review
· Review of home task
· Introduce thought challenging
· Set home task
· Client item: Nothing to bring today
· Feedback on session
Problem
Statement/Formulation details:
Reports a steady decline in
mood over the past few years. Struggles
with thoughts of losing his job and easily becoming stressed over daily
tasks. Significant levels of self-critical
thinking linked with various difficult life experiences.
Goals:
To focus on being more optimistic and to reduce negative thinking – by
capturing the positive aspects of his day, not just the problems being faced.
To reduce rumination and self-critical thinking and to be more positive about
the future.
Current
rating of success around goals: 4/10
Beckian longitudinal
formulation completed.
Review
In-between session:
James was asked to keep a thought record and identify
unhelpful thinking habits.
James completed this successfully and gathered thoughts such
as: “I am no good at my job and will get sacked” (belief rating 7/10) which
brought about feelings of depression and hopelessness, he also identified “All
of my colleagues are judging me” (belief rating 8/10) which for him lead to
feelings of anxiety.
James was able to label his thoughts as ‘catastrophising’ and
‘mind reading’.
On reflection James was able to see the links between his
thoughts and emotions.
Content of
Session:
MDS review: James’s scores on the PHQ9 and GAD7 have increased
since last session. We explored this further, and this is due to news from work
that they are making significant redundancies.
Introduced thought challenging to James, using the 7-column
thought record.
Used a thought from his home task to challenge in session today:
Situation: sent a work email
with a spelling mistake.
Emotion: hopeless (80%), depressed (80%).
Thought: “I am no good at my job and I will get sacked”.
Evidence for: James was not able to identify any evidence
to support the thought and was able to separate evidence from opinion. He said
that work are currently making redundancies – we explore whether this was a
fact to support his NAT and he was able to see that it wasn’t.
Evidence against the
thought: 1) It was a minor spelling mistake. 2) I sent the email a week ago and
my manager has seen it but not called me into his office to discuss. 3) I have
recently had a good annual appraisal.
Challenged thought: “I may
have made a minor mistake but that does not mean I am no good at my job,
everyone makes mistakes”.
Emotion: hopeless (0%), depressed (0%).
Used this challenged thought and linked it back into the formulation (Beck
formulation). James was able to see how his negative automatic thoughts are
driven by his core beliefs and rules for living.
Agreed between session task:
Discussed between session
task and James felt he wanted to practice using this revised thought whenever
he notices thoughts of being no good at his job. James also to look at
repeating thought challenging process with at least one other negative thought over
the course of the week. James feels able to do this and did not indicate any
barriers to completing this.
Treatment Plan:
Beck cognitive model of
depression.
Completed: Formulation,
psychoeducation and thought challenging.
Next steps: Moving towards
working on rules for living and core beliefs. We will incorporate behavioural
experiments to test out new rules/beliefs.
Session
feedback and Learnings:
James reported finding the
above exercise “really helpful” and “interesting”. James was able to reflect on
the biased nature of his thoughts, and he could see the benefit of looking at
factual evidence. James
said that he was however slightly “distracted” from today’s session due to the
ongoing situation at work.
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 2 on PHQ9 Q9. James
has, to date, scored 0 on this question. We explored this increase in risk, and
he said that this was triggered by news of redundances at work.
Thoughts: “They are going to
make me redundant, and I won’t be able to provide for my family – what’s the
point of being alive if I cannot do that”.
Current Plan:
James had no specific plans
to act on the thoughts identified above. However, he said that if he was to act
on the thoughts he knows that he would take an overdose of over-the-counter
medication (James has a history of taking an overdose – see below)
Access to Means:
James said that he has not
actively started to stockpile medication however he said that he does have a
“couple of packets of both Paracetamol and Ibuprofen at home for medicinal
purposes.
Intent Rating:
2/10
Self-harm
Thoughts:
James
did not disclose any self-harm based thoughts or plans.
History:
James has disclosed one historic suicide attempt. This was 7 years
ago, and he has not made any attempts since then. James said that he was in a
difficult place at the time following several bereavements in a short space of
time.
He took an overdose of 30 x Paracetamol and
20 x Ibuprofen. He was taken to hospital for treatment and was seen by the
Psychiatric Liaison team based in A&E. No further action was taken
following this.
Risk Factors:
Redundancies at work
James has started to drink
2-3 pins of beer after work in an evening, he previously didn’t drink.
Recreational drugs: None reported.
Current
Triggers:
Redundancies at work.
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:
We have completed a written
safety plan today and this has been sent to james (see health history for a
copy of this).
James has confirmed that he
can keep himself safe and would reach out to support services if risk increased
further.
Risk
Formulation:
James is currently
presenting with a risk in suicidal thoughts, and whilst he has no specific plans,
he said that if he was going to act on the thoughts, he would take an overdose,
and he has a history of doing this.
James identified his
protective factors as his wife and family, however his suicidal thoughts centre
around not being able to provide for his family.
We have covered a safety
plan in today’s session that he will keep on his phone and said that he will
reach out to support services if risk increases.
I am going to write a letter
to his GP informing them of the increase in risk.
Clinician Requests
Please use
this section to complete any additional sessions requests or request for
clinical review.
Does this
clients risk presentation require review by VHG Risk Duty?: * Yes
If yes
Rationale for risk review:
Please can
today’s increase in risk presentation be reviewed and can you advise if any
further action is warranted. I am concerned about James’s protective factors
and the fact that these are also tied up in his suicidal thoughts too.