The Practice Notebook of a Psychotherapy Trainee: Choosing the Patient for CBT
I am a nervous wreck! I am to conduct my very first series of cognitive behaviour therapy (CBT) sessions as a resident physician training in psychiatry. I have read Dr. Beck’s “Cognitive Behaviour Therapy” and Dr. Padesky’s “Mind over Mood.” I can explain the theoretical model behind CBT. I know the structure and techniques of CBT. I have read about and observed the Socratic Method of “guided discovery”. I can identify cognitive distortions and know about the techniques used to help to change them. My preceptors and lecturers have done well in preparing me for my first patient, but I am going into uncharted territory! I have never done any of the cognitive and behavioural techniques I have only read about. Up until now, my medical training has been focused exclusively on pharmacological treatment of mental disorders. Now in my second year of training to become a psychiatrist, I am introduced to a new treatment entirely dependent on therapeutic interactions with the patient. “Nervous” did not describe my feelings exactly. I was closer to a panic!
In this new series of blogs, I will attempt to answer the questions of a novice trainee in psychotherapy.
Who will benefit from psychotherapy?
Being a novice trainee in psychotherapy, I was advised that the most wise course of action was to practice psychotherapeutic skills with consenting patients who are most likely to benefit from talk therapy. Who are these patients?
Dr. Paul Blenkiron asked this very same question and attempted to answer it in this review.
According to Blenkiron the ideal patient …
- Accepts that psychological reasons are responsible for his or her difficulties
- Is motivated to change and is willing to attend regular sessions
- Is able to access and identify his or her feelings
- Is able to make psychological connections
- Is able and willing to form meaningful relationships
- Does not have a chaotic life and does not have multiple long-term problems
- Is able to tolerate anxiety
- Has adequate impulse control
The patient who is suitable for a cognitive-behavioural approach specifically is one who:
- Is able to identify and define key problems
- Is focused, active, able and willing to complete homework assignments
- Accepts that improvements in mood and emotions is possible by identifying and modifying associated thoughts and behaviour
- Is willing and capable of participating in a therapeutic relationship that is collaborative (based on the Socratic questioning technique)
- Has identifiable problems amenable to treatment goals based on the cognitive model for the connections between thoughts, emotions, and behaviour
- Shows positive response to the rationale behind this cognitive model
- Is able to tolerate and follow through with behavioural experiments to test out beliefs
These lists are a wonderful description of the “perfect” patient. However, these lists do not help me to answer the next question.
Do I choose patients based on the need for talk therapy or based on some “innate potential” to benefit from talk therapy?
If I chose based on need, then I would set out to look for cognitive or behavioural deficits that cause mental distress (like depression or anxiety) in patients. If I chose based on potential to change, then I would set out to look for patients who have sufficient self-awareness and potential to improve on their existing strengths.
Dr. Mary Beth Connolly Gibbons and her colleagues at the University of Pennsylvania, attempted to answer this very question (read it here). The authors used pooled data from multiple studies conducted between 1995 and 2002 at the University of Pennsylvania Center for Psychotherapy Research. The levels of baseline deficits in compensatory/coping skills and self-understanding were measured for 184 patients and correlated with outcomes in various psychotherapy treatments. Psychotherapy treatment studies included alliance-fostering psychotherapy, cognitive therapy, family therapy, relationship-focused therapy, supportive-expressive dynamic therapy, and supportive therapy.
The authors found that regardless of patient characteristics before talk therapy for depression and anxiety, there were large and significant reductions in symptoms independent of psychotherapy type utilized. The patients who benefited most from cognitive therapy were those suffering from depression who were already relatively strong in compensatory or coping skills before therapy. The data on self-understanding and outcome of therapy, as well as for dynamic therapies were inconclusive. A limitation of this study was that a total of 411 patients were recruited and only 184 were deemed eligible for psychotherapy. Perhaps these patients were pre-selected to succeed in talk therapy!
What this means is that I can expect the best results from cognitive therapy for patients who already have innate potential to improve on their existing strengths.
How do I assess for this potential? Again, Dr. Blenkiron made some suggestions. He provided a short list in his review (read it here).
Indicators determining who would most benefit from short-term CBT:
- Understanding and acceptance of the CBT model of therapy
- Ability to recognize and examine automatic thoughts
- Ability to recognize and examine shifts in emotion and make links to thoughts
- Ability to form collaborative, meaningful long-term relationships
- Capable of describing examples of difficulties
- Capable of accepting others’ input for change
- Capable and motivated to take personal responsibility for change
- Current difficulties are not pervasive life-long patterns
Practically speaking, I can use the first assessment interview to determine suitability for short-term CBT by looking for these characteristics in my patient.
My very first psychotherapy session went well without any obvious mishap. CBT is highly structured and for a novice psychotherapist trainee like me, following Dr. Beck’s and Dr. Padesky’s clear instructions was the key to success. The CBT approach was my entry into providing talk therapy but I hope to learn the theories and techniques of a wide range of other types of psychotherapy. Learning how to apply various types of talk therapy effectively will be challenging. Knowing when to provide which type of therapy takes experience and training. As I improve in skill, knowledge, experience, and confidence, I hope to eventually not have to “choose” the patient, but instead to tailor my psychotherapeutic approach (or referral) to match best with any patient. I am very excited to be undertaking this journey.
1. Blenkiron P. Who is suitable for cognitive behavioural therapy? Journal of the Royal Society of Medicine. 1999;92(5):222-229. Read it here.
2. Gibbons MBC, Thompson SM, Mack RA, Lee JK, Crits-Christoph P. The Relation of Baseline Skills to Psychotherapy Outcome Across Diverse Psychotherapies. Journal of clinical psychology. 2015;71(6):491-499. doi:10.1002/jclp.22165. Read it here.
In the next blog of this series, I will examine the question: Why is psychotherapy effective?
The views expressed in these blogs are the author’s own and not necessarily reflective of those of Psychotherapy Matters. Copyright © 2015 PsychotherapyMatters.com