EVIDENCE-BASED PRACTICE OF COGNITIVE-BEHAVIORAL THERAPY

SAMPLE INITIAL INTERVIEW FOR COGNITIVE-BEHAVIORAL THERAPY

Name: __________________________________ Date: ________________________

Discuss consent for assessment, confidentiality, and limits to confidentiality; purposeof

assessment; reporting system; and any training purposes for the assessment and observation.
Obtain consent. Mention that you will be taking notes during the interview. Provide opportunity
for questions. Describe what will occur following the assessment (e.g., report, follow-up
appointment).

GENERAL INFORMATION

1. Age and date of birth.

2. Marital status (if single, recent relationships). Any children (names and ages, if
appropriate)?
3. Current living situation. With whom do you live? What is your accommodation?
4. How are you currently supporting yourself? Do you have any financial problems?
5. Brief employment history.
6. What is your level of education? What year did you graduate?
7. Reason for referral and description of current problem(s).
o Situations when the problem occurs (obtain detailed list).
o Situations that are avoided (or endured with great difficulty) because of the
problem.
o Rating of current functioning (from 1 = “best ever” to 10 = “worst ever”).
o Impact of the problem upon current functioning (0–100% affected).
o Which area(s) of your life are most affected (e.g., school, work, friendships,
family)? Least affected?
o What is the most difficult thing for you to do because of the problem(s)?
o What are your typical reactions when you are experiencing this problem(s)?
 Physical reactions (include panic attacks)
 Emotional reactions
o What are your thoughts before, during, and after the situation? (Primer questions
include “What do you imagine happening if . . . ?” It is helpful to have specific
examples or images to identify thoughts.)
o What do you typically do when this happens?
o Have you noticed any patterns to these reactions (e.g., times when things get
better or worse; times of day, days of the week)?
o What other factors affect how you feel in these situations (e.g., other people,
environmental factors, duration of situation, your own or others’ expectations)?
o What have you found that helps to reduce the problem(s) (e.g., can be divided
into negative and positive coping, use of medications, strategies learned in
previous therapy, self-help methods)?
o Are there ways that you try to protect yourself when you are experiencing these
problem(s)? Are there small things that you do to help yourself “get through”
situations (e.g., making preparations, taking medications, asking for reassurance,
relying on other people, avoiding certain aspects of the situation)?
o Can you think of any skills that you might develop that would decrease the
problem(s) (e.g., social skills, conflict resolution, job skills)?

From: Dobson & Dobson (2016) - Evidence-Based Practice of Cognitive-Behavioral Therapy

 8. Aside from the problem(s) we have just discussed, are there other current stressors in
your life right now? What are they?
9. How would you describe your current mood? Rating is from 1 to 10 (“worst”).
o If you feel low or depressed, how long have you been feeling this way?
o Have you lost interest in things that you previously enjoyed?
o How do you feel about the future?
o How have you been sleeping recently? How is your appetite?
o Have you ever thought about harming yourself (differentiate suicidal behavior
from self-harm behavior)?
o If yes, assess when, the frequency, the method, history of attempts, and family
suicide history.
o What holds you back from hurting yourself?
o Have you had treatments for depression? If yes, when? How effective were they?
10. Do you have any other current psychological concerns?
11. How is your physical health? Do you have any concerns? Current medications (type and
dose)?
12. Tell me about any other drug and alcohol use, including caffeine. Have you had any past
problems with substance abuse? Any treatment history for substance use?
13. Are you currently involved in any community programs or volunteer work?
14. What do you like to do in your free time?
15. History of current problems—When did your problems begin? Can you remember a
specific incident that you believe caused the problem?
o What were you like as a child and adolescent? Do you remember (or have you
been told about) any developmental problems? What were your school and
family experiences like growing up?
o Did you have any family problems growing up? Do you have a history of any type
of abuse?
o Have you ever sought help for any psychological or psychiatric problems in the
past?
o Is there anyone in your family with a history of anxiety disorders, depression,
substance abuse, and so forth? Is there anyone in your family that you consider
to have problems similar to your own? Is there any family psychiatric history?
16. Who is in your family of origin? Provide the first names of your parents and siblings;
provide their current ages and where they live
17. Who are you closest and least close to in your family? Who would you approach for
support? Who would you approach in the event of a crisis or emergency?
18. Have I missed anything?
19. Use three or four adjectives to describe yourself as a person (including strengths and
weaknesses). (If client is unable to describe him- or herself, ask how someone who
knows the client very well would describe him or her.)
20. What are some of your hopes and goals for being here? What are one or two things you
would like to change about the problem(s) we have discussed?
21. Do you have any questions? (Explain to the client what will happen next.)

BEHAVIORAL OBSERVATIONS:
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From: Dobson & Dobson (2016) - Evidence-Based Practice of Cognitive-Behavioral Therapy

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From: Dobson & Dobson (2016) - Evidence-Based Practice of Cognitive-Behavioral Therapy

 Approach Cognition Behavior Emotional Interpersonal

Cognitive - Thought - Activity - Affective

Therapy monitoring monitoring (link education
Goal: (Identification of activity, thoughts, (distinguish
Understand the negative and feelings; between core
link between automatic Identifying emotions; identify
thoughts, thoughts, core maintaining physiological
feelings, and beliefs / schemas, factors) symptoms)
behavior and dysfunctional - Goal planning - Affective
assumptions) (Identify and agree monitoring
- Identification of goals) (Link feeling with
cognitive - Target setting thoughts and
distortions and (Practice tasks, behavior; scales
deficits increase enjoyable
(Common to rate intensity)
activities, activity - Affective
dysfunctional rescheduling) management
cognitions, - Behavioral (new skills)
assumptions and experiments
beliefs, patterns (Test predictions /
of cognitive assumptions)
distortions, - Graded exposure
cognitive deficits) / response
- Thought prevention
evaluations - Learn new skills /
(Testing and behavior
evaluating (Role play,
cognitions, modelling,
cognitive rehearsal)
restructuring, - Reinforcement
development of and rewards
balanced (Self-
thinking) reinforcement, star
- Development of charts,
new cognitive contingency
skills contracts)
(Distraction,
positive diaries,
positive and
coping self-talk,
self-instructional
training,
consequential
thinking, problem-
solving skills)

From: Dobson & Dobson (2016) - Evidence-Based Practice of Cognitive-Behavioral Therapy

 EVIDENCE-BASED PRACTICE OF COGNITIVE-BEHAVIORAL THERAPY

Steps:
1. Developing the Problem List,
2. Developing the initial case formulation, and
3. Communicating the case formulation and assessment results

1. Use the most reliable and valid assessment tools possible

2. Emphasize the use of descriptive and objective data where possible.
3. Ensure that you consider contextual, personality, and relationship factors in your
formulation, particularly as DSM-5 no longer requires a multiaxial diagnosis.
4. Limit the range and number of inferences you draw from the available information.
5. Use a consistent and structured approach to case formulation. Revisit and re ne your
case conceptualization as new data become available.
6. Be open to alternative hypotheses.
7. Test your hypotheses against what you observe over time in therapy; be especially open
to new information that is inconsistent with your case conceptualization.
8. Obtain feedback on your case formulation from the client and others who know him or
her well.
9. Consider using a manual-based approach or low-intensity treatment if the presenting
problems are straightforward. Otherwise, you may be tempted to “overcomplicate” the
underlying basis of a client’s problems and use a more idiographic, but no more
effective, treatment.

From: Dobson & Dobson (2016) - Evidence-Based Practice of Cognitive-Behavioral Therapy

 SAMPLE REPORT

Initial assessment for cognitive-behavioral therapy report. Adapted from Cognitive

Therapy Subgroup, Outpatient Mental Health Pro- gram, Calgary, Canada. This report
format may not be practical in all set- tings and will require adaptation. Used by
permission of Dr. Kerry Mother- sill, Cognitive Therapy Subgroup Supervisor.

Client Name: Stephen R.

Referral Source: Dr. Z.

Date of First Session: October 4

Date Assessment Completed: October 11

Referral Source and Presenting Concerns

Stephen R. was referred by his family physician for cognitive-behavioral therapy for
depression, anxiety, anger, and potential substance abuse. He presented with a number
of current concerns, which included depressed mood, guilt, irritability, uncontrollable
worry, increased drinking, and feelings of “uselessness.”

IDENTIFYING INFORMATION

Stephen R. is a 42-year-old married man. He is trained as a bookkeeper and normally

works full-time for a large corporation in a senior bookkeeping role. He reports directly
to an accountant, who is also the chief financial officer. He has been in his current job
for 12 years, and two more junior staff report to him. He has three children, a son age
12, a daughter age 9, and another son, age 6. His wife is a licensed practical nurse and
works part-time in a medical unit at a large urban hospital. They have been married for
15 years. Stephen has been on a disability leave from his job for the past few months.

CURRENT SITUATION AND BEHAVIORAL OBSERVATIONS

Stephen presented early for his appointment. His demeanor was serious and earnest.
His interpersonal style was somewhat detached, and he initially appeared unemotional
and sometimes used the third person when he described his problems. He was fully
oriented and there were no indications of difficulties with disordered thoughts, poor
concentration, or memory. He appeared well prepared for the assessment, with a
notebook in hand. He had done background research on cognitive-behavioral therapy
and possible diagnoses related to anxiety and depression, as well as research on the
interviewer. His affect was initially quite flat, however, during the initial interview. He
gradually appeared more and more sad and became tearful when he talked about
his current situation and recent past events in his life. When he expressed sadness, he
appeared agitated and he became fidgety and uncomfortable. He spontaneously talked
about himself in self-derogatory ways, saying that he “felt useless,” like a burden to his
family, and wondered if they would be better off without him. He was fully cooperative,

From: Dobson & Dobson (2016) - Evidence-Based Practice of Cognitive-Behavioral Therapy

respectful toward the interviewer, but avoided eye contact and appeared somewhat
eager to complete the interview.

Stephen reported numerous current problems. He completed both the PHQ-9

and the GAD-7, both of which demonstrated clinically significant scores of 18 and 14,
respectively. He stated that he felt anxious and sad most of the time and was easily
irritated by everyday events. He was very self-critical and reported intense feelings of
guilt over his performance at work and being on short-term disability. He reported
suicidal ideation, some hopelessness about the future and feelings of worthlessness.
His appetite and libido were somewhat reduced, although he had not gained or lost any
weight. He experienced many negative thoughts about himself as well as others. While
he had doubts about his own abilities, he had low expectations for others
as well. Stephen had no history of suicide attempts and reported that he had no current
intention to harm himself. He had not considered methods of self-harm, nor did he own
any weapons. He reported frequent, uncontrollable worry. The content of his worries
was his own mental health, his finances, how he would be perceived when he returned
to work, his performance at work, and how he would manage once he returned to his
job. Stephen had difficulties falling asleep most nights and reported that he felt tired and
his energy and motivation were both low. Because of his insomnia, he was tending to
stay up late at night and would return to bed in the morning once his wife and children
had left the house.

Stephen met diagnostic criteria for major depressive disorder and generalized
anxiety disorder and also showed some features of social anxiety disorder, as he
described himself as socially reticent and preferred being around only one or two people
at a time. He worried about negative judgment, particularly regarding his work or social
competence. He tended to defer to others and relied upon his wife to organize social
activities. He reported that he had few friends and did not socialize with colleagues
outside of work-related social events. He described himself as a “private” person and
did not like other people to know about his personal life.

In terms of his family, one of his children has Type 2 diabetes and another had a
mild learning disability. His wife had no known health problems, and he reported that he
and his wife were reasonably happy in their marriage. His depression had created some
stress in the family, and he felt extremely guilty being off work. His wife had taken on
more shifts at the hospital to help pay the bills. They lived in their own home; however,
he reported that they had a large mortgage and a car loan.

At the time of the initial interview, Stephen reported that he spent his days
reading, doing household chores, picking his children up after school, and taking them
to their activities. He acknowledged that it was very difficult for him to get out of bed in
the morning and he had limited motivation for self-care. His interest in his usual
activities was low, and he had stopped going to the gym or doing outdoor activities
during the day, as he feared that neighbors would see him and realize that he wasoff
work. He believed that they would think that he was a “loser” if they saw himat home
during the day. He was staying up late at night after his family was in bed, doing Internet

From: Dobson & Dobson (2016) - Evidence-Based Practice of Cognitive-Behavioral Therapy

searches and reading news and financial information. He would drink three to four beers
each night, or several glasses of wine over dinner, which was a considerable increase
in consumption.

Stephen’s interpersonal style was distant and detached, although he became

tearful and agitated when talking about his problems. He described himself as
hardworking, conscientious, and somewhat perfectionistic. He approached his work with
precision and had received positive feedback for his accuracy in the past. He reported
that he had been promoted 2 years prior and had taken on the role of managing two
recently hired junior employees. He struggled with this role, particularly providing
performance reviews and critical feedback.

Stephen reported that he was in good physical health, although he felt sluggish
and tired most of the time. His appetite was normal; however, his consumption of
alcohol had increased considerably in the past few months. He reported that he had
been taking antidepressant medications for the past 6 months and was aware that the
combination of alcohol and medications was unwise.

PROBLEM LIST
1. Lack of structure and meaningful daily activities 2. Insomnia
3. Poor communication skills
4. Emotional avoidance, particularly of anger
5. Negative self-image
6. Uncontrollable worry
7. Depressed mood and thoughts of suicide 8. Lack of social support
9. Worries about finances, and return to work

DIAGNOSTIC EVALUATION
Stephen meets diagnostic criteria for major depressive disorder and generalized anxiety
disorder, with likely social anxiety disorder.

RELEVANT HISTORY

Current Episode

Stephen reported that since he received a promotion 2 years ago, he had struggled
somewhat with the interpersonal demands of managing other employees. There
was an incident at work just over 6 months ago where he reported that he “lost it”
following an incident where one of his supervisees had made a serious error that cost
the company several thousand dollars. The company had had other financial difficulties,
and there had been rumors of layoffs and cutbacks. Stephen became very angry with
the employee and was verbally aggressive. He recognized almost immediately that his
behavior was inappropriate, at which time he left work, took a walk over a bridge, and
contemplated jumping into the river. Recognizing his risk, he called his wife, who took
him to the emergency room at a hospital. Following a mental health assessment, he
went to see his physician, medication was prescribed, and several months later, he was
referred for cognitive-behavioral therapy. Stephen had attempted to return to work 3

From: Dobson & Dobson (2016) - Evidence-Based Practice of Cognitive-Behavioral Therapy

weeks prior to the intake interview but found it extremely anxiety provoking and difficult
to manage. He was at work for half a day and returned home highly anxious, agitated,
and discouraged.

Treatment History

Stephen went to see his family physician 6 months ago, following the mental
health assessment in the emergency department. His family physician completed a brief
screening interview and prescribed antidepressant medications, and he was placed on
short-term disability. Several months later, not only had Stephen’s symptoms not
improved, they had worsened, so a referral for cognitive-behavioral therapy was
initiated. Stephen had no prior experience with psychotherapy, although he reported two
prior episodes of depression. During the initial interview, he reported that he had been
diagnosed with major depressive disorder, once shortly after he completed his training
at a community college and the second time when he lost his job 3 years after he and
his wife moved to the city where they currently live. He lost the job due to downsizing
rather than any performance problems. He had been treated with medications on both
occasions. He had no history of hospital admissions, suicide attempts, or substance
abuse treatments.

Relevant Background

Stephen is the eldest of two sons. His younger brother is an accountant in the
town where he grew up. His father is retired but worked in the financial industry for
many years and was quite successful in his career. He reported that he admired his
father and did not feel as though he has lived up to his expectations. His mother is also
retired and up to fairly recently worked as an elementary school teacher. He described
his childhood in positive terms and reported that there was a great emphasis placed
upon hard work, financial stability, and “family values.” He was a good student but
struggled somewhat socially due to his shy and serious nature. He was not athletic and
experienced some teasing about being “too serious” and a bit of a “nerd.” He did not
have any history of any type of abuse or trauma, although he had been quite anxious
about becoming depressed again following his prior episodes. Following the completion
of college and after his marriage, Stephen and his wife moved to a large city for better
employment opportunities. Because his family lived several hours away, he had not told
them about being off work. While he described their relationships as close, they
generally did not talk about feelings or personal matters very much. He was not
particularly close to his brother and he indicated that they are only 18 months apart in
age and have always been quite competitive with each other. He believed that his
brother has been much more successful than he has been.

COGNITIVE-BEHAVIORAL FORMULATION

Stephen grew up in a family where he obtained reinforcement for hard work, financial
responsibility, and the belief that men were responsible for earning a good living and
supporting their family. He placed value on “doing the job” correctly and had typically

From: Dobson & Dobson (2016) - Evidence-Based Practice of Cognitive-Behavioral Therapy

received positive feedback for his approach to his education and his work. He viewed
himself as serious, capable in his job, but as socially awkward and inept. Stephen had
been teased during his school years, so he tended to avoid social interactions and saw
himself as socially inadequate. He struggled to understand other people. His early
family experiences did not include the expression of negative emotions or vulnerability
except through avoidance or irritability. He also remembers his father making
disparaging comments about a neighbor undergoing treatment for depression,
describing him as weak and ineffectual. Stephen devalued social relationships in favor
of hard work. He appeared to have underlying beliefs that others judged him negatively
and that the primary goal in life was stability, security, and success at his job. While he
did not report particular struggles with life transitions, his three depressive episodes all
occurred shortly after periods of transition or increased responsibility. He tended to
downplay his need for social support, and his major motivator for treatment was to have
a successful return to work.

RELEVANT CLINICAL OUTCOME RESEARCH

Many studies have demonstrated the benefit of cognitive-behavioral therapy for
the treatment of depression and anxiety. This treatment focuses on behavioral
assignments that increase behaviors associated with feelings of mastery and pleasure,
the identification and restructuring of negative automatic thoughts and emotions, and
the assessment and potential change of the client’s beliefs. Meta-analyses demonstrate
that cognitive-behavioral therapy is highly effective for depression (Cuijpers et al., 2013)
and generalized anxiety (Cuijpers et al., 2014), with outcomes that at least equal the
effectiveness of other therapies and create longer-term change relative to drug
therapies.

RECOMMENDATIONS AND TREATMENT GOALS

Cognitive-behavioral therapy was recommended for Stephen. Therapy sessions were
scheduled for once a week and initial treatment goals were discussed. In addition to
helping with a successful transition back to work, Stephen indicated that he believed he
would benefit from an increase in structure and meaningful activities and from learning
ways to manage his worry, anxiety, and irritability, as well as learning more effective
communication skills. He acknowledged that learning some ways to deal with conflict at
work would be beneficial. Treatment goals include the following:

1. Orientation to the cognitive-behavioral model.

2. Building and strengthening a collaborative therapeutic alliance.
3. Provision of psychoeducation.
4. Increased structure and scheduling of daily activities, particularly mastery.
5. Assisting with successful return to work.
6. Communication skills training, particularly conflict resolution.
7. Increasing awareness and tolerance of distressing emotions, particularly anger.
8. Monitoring of thoughts and restructuring of dysfunctional beliefs.
9. Possible worry or social exposure.
10. Ongoing monitoring of suicidal ideation and substance use.
11. Increasing social support.

From: Dobson & Dobson (2016) - Evidence-Based Practice of Cognitive-Behavioral Therapy

 12. Schema therapy near the later stages of treatment, if appropriate.

ANTICIPATED FACTORS AFFECTING OUTCOME

Stephen is very motivated to return to work and return to his role as a provider to his
family. Although he was somewhat reticent when treatment was recommended, he is
now interested in a structured, goal-oriented approach with empirical evidence. This
approach appeals to him as practical and empirically supported. His tendencies to be
hardworking and conscientious are likely to be helpful in treatment. In addition, he is
very distressed but is aware that some of his current coping strategies (e.g., staying up
very late; drinking alcohol) are counterproductive. He is interested in improving his
coping skills, particularly those that might ensure greater success on the job. These
factors made him a good candidate for therapy. On the other hand, his primary
motivator is to return to work rather than to change his approach to his life as a whole.
He is socially awkward, which is apparent in his approach to the therapist. His
interpersonal tendencies to avoid difficult topics and to be reserved are likely to be
present within the therapeutic relationship. He may be reluctant to bring up negative
reactions, and his tendency toward anger could interfere with progress. In addition, if he
successfully returns to work, he may withdraw from treatment prior to successful
treatment of the problems that led to his depression.

Deborah Dobson, PhD, RPsych

Cc: Dr. Z.

From: Dobson & Dobson (2016) - Evidence-Based Practice of Cognitive-Behavioral Therapy