Cognitive Behavioural Therapy

Lesson 3

Consultation
Formulation
Clarifying the Problem
Client Confidentiality and Consent
Data Protection and Disclosure

The Consultation process

All CBT practitioners keep client records, some manual, some on computer.

However you choose to keep records, the important thing is to ensure that you
obtain all necessary and relevant information.

If you agree to deliver a course of treatment, you will need to make a note of
fees agreed, payment methods, and monies outstanding.

As time goes by, you will need to update your client information.
It is important to note:

 The dates you meet with clients.

 Any homecare or home work given.

 Effects and feedback from sessions.

 How the client is feeling, including any changes to lifestyle and lifestyle
management suggestions.

 Any agreed changes to the CBT process plan.

 Any problems with client payment.

Before any treatment can commence, the practitioner needs to find out why the
client feels that they need to engage your services and what their expectations are
of the therapy and of you, the practitioner.

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In effect, the consultation process serves as a fact finding mission for both parties.

The practitioner will need to determine medical, social and emotional history their
current life whereabouts and what they, the client feel they require. The client
also has a chance to find out about the CBT process, what it entails and whether
it is actually suitable for their requirements.

Many CBT practitioners will offer a free 15 minute informal meeting before the
client actually gets to the consultation process in order to make sure that they
know enough about the CBT process to have already made the decision that that
is the route they would like to go down.

As the first professional contact between client and practitioner, the consultation
also helps to establish a professional relationship. This is important in all
therapies but especially in CBT as the client will need to be very open about their
emotions, their hopes, aspirations and fears.

Thus the practitioner can reassure the client about any aspect of treatment that
concerns them, thus helping an anxious client to relax.

A consultation should cover the following information:

 The client‟s expectations and whether these are realistic.

 What the treatment/sessions will involve and any possible effects (i.e.
dispelling any unrealistic expectations)

 Personal details: name, address, telephone numbers, date of birth, GP‟s

name and address.

 Medical background; medical conditions, previous illnesses or diseases,

operations, allergies etc.

 Diet and other factors; eating habits, fluid and alcohol consumption,
smoker or non-smoker, drug or substance use, coping strategies – positive
or negative, sleep problems.

 Integral biology: work environment, family environment, and lifestyle –

sedentary or active.
 Stressors, personal stress management.

 Presenting problems/ issues.

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 Presenting fears.

 Therapy treatment history

A consultation should take place in a comfortable, private room, where there is

no chance of interruption. The room can be used for consultation and CBT
sessions as long it is possible to do so in a relaxed manner i.e. not sitting behind
a desk and by trying to project an open, friendly and professional image – keeping
arms and legs uncrossed, establishing good non-invasive eye contact and smiling
when appropriate.

The client must feel reassured and comfortable in order to answer the
questions and also to fully benefit from the sessions.

A new client may feel a little uneasy or nervous about the consultation process
and revealing very personal information to you. Your first task will be to reassure
them and relax them by explaining how the process and session will run, how all
information given will remain confidential and how the sessions will be geared
to their individual needs.

The next step is to encourage them to volunteer the required information. You
will soon be able to judge how to approach this with different clients.

For example, an open and relaxed person will need little coaxing but with a shy,
reticent client a practitioner will need to demonstrate listening skills.

The following list of suggestions will help you get the most from a consultation.

Start with general questions or, if you want to prompt, or sense a particularly shy
client, use the consultation form as a starting point.

Once you have begun asking questions which are easy to answer (name, address,
date of birth etc) the more difficult ones about treatment won‟t seem so daunting
– the client will be in the rhythm of responding to your questions and will actually
expect them rather than be made more nervous.

Ask open not closed questions – ones that cannot be answered with yes or no.
For example, ask, “What do you expect from CBT?” instead of “Do you think
CBT will work for you?”

In the early stages of treatment, no-one likes to examine their own habits so it is
best to address the questions in as open and unthreatening a manner as possible.

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In order to instil trust, use your own body language to encourage and aid
responses: nodding, smiling and leaning forward all communicate interest as does
keeping eye contact.

Looking away frequently, fidgeting or staring blankly will merely communicate

nervousness and/or lack of any interest, which will not help the client to feel
confident in your abilities or your interest in them.

Remember, as a professional CBT practitioner, you are there to help the client.
If you are unfriendly, nervous or uncommunicative the client is likely to pick up
on this and react in a similar way.

Be confident, enthusiastic and professional at all times in your interactions with

the client.

Communicate your own belief and trust in the treatment and this will help the
client to believe in it and this will improve the psychological and physiological
effects of the CBT process.

Reassure the client that everything discussed will remain completely confidential
and make sure you never break this confidence.

Treat everyone equally.

If you cannot avoid bringing sexist or racist prejudices to the session then
this is definitely not the profession for you.

On the next page is an example of a client consultation form that could be used
in CBT treatment.

As you can see the level of information asked for is quite detailed and this is
necessary for the therapist to get a really in-depth physical and emotional picture
of the client and this is useful to be used in conjunction with the formulation
process.

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THIS DOCUMENT IS PRIVATE AND CONFIDENTIAL.

CBT

The following information is required for your safety and to benefit your health. There
may be certain contraindications, which will require special attention and/or further
discussion.
It may be necessary to consult with medical practitioners before any treatment can be given. The
following details will be treated with the strictest confidence.

Clients Name

Address

Sex: Male  Female 

Date of Birth
Height
Weight
Tel No: Day: Eve:
Mobile:
Work:
Email:
GP Address
Profession

Marital Status: Single  Married  Separated  Divorced  Widowed  Co-Habiting 


No. & age of Children or Dependants?

Women Only:
Pregnant: N/A  No  Yes  How many months?

Have you recently experienced a miscarriage or termination?

Are you currently
menstruating?

Parental History:

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Medical History / Operations:

Medication / Present Health:

Are you presently or have you ever taken the following: -

Opiates Yes  No . If Yes, when last

taken
Stimulants Yes  No . If Yes, when last
taken
Hallucinogenic Yes  No . If Yes, when last
taken
Benzodiazepines Yes  No . If Yes, when last
taken
Cannaboids Yes  No . If Yes, when last
taken
Solvents Yes  No . If Yes, when last
taken
Amphetamines Yes  No . If Yes, when last
taken
Alcohol Yes  No . If Yes, when lasttaken
Nicotine Yes  No . If Yes, when last
taken

Reason for Treatment:

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Do you suffer from any of the following?

Muscular / Skeletal Problems: Neck  Back  Rheumatism  Arthritis  Aches and pains  Stif
Joints  Headaches 
Digestive Problems: Constipation  Diarrhoea  Bloating  Liver/Gall Bladder  Stomach  Diabetes

Circulation: Heart  Blood Pressure  Fluid Retention  Tired Legs  Varicose Veins  Cellulite 
Kidney Problems  Cystitis  Cold Hands and Feet 
Gynaecological: Irregular Periods  PMT  Menopause  HRT  Pill  Coil 
Other

Nervous System: Sensitive  Migraine  Tension  Headaches  Stress  Depression 

Epilepsy 
Immune System: Prone to Infections  Sore throats  Colds  Chest  Sinuses  Regular Antibiotics
Taken 

Have you ever been diagnosed with cancer? Yes  No 
If Yes Details

Professional Life - Employment details

Ability to relax: Good  Poor  Average 


Time to relax: Hobbies or creative interests?

Do you exercise? None  Occasional  Irregular  Regular  Types?

Sleep patterns: Good  Poor  Average No.of hours?

Do you see daylight in your workplace? Yes  No 

Do you suffer from: Nervous tension  Depression  Anxiety 


On a scale of 1-10 (10 been the most stresses), how stressful would you say your life is currently?_

On a scale of 1-10 (10 been the most stresses), how stressful would you say your work life is currently?

Are you currently experiencing major stressors in your life e.g.: Bereavement, divorce, birth, marriage,
moving house, changing jobs, personal or family illness etc? Yes  No 

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


Do you eat regular meals? Yes  No 


Do you eat in a hurry? Yes  No 

Do you take food / vitamin supplements? Yes  No 

Would you say you had a healthy diet? Yes  No 

Is your diet well balanced? Yes  No 


How much of each of these does your diet contain?

Fresh fruit:

Fresh vegetables:

Protein (Source):

Dairy produce:

Sweet things:

Added Salt:

Added Sugar:

How many daily drinks Tea: Coffee:

Fruit Juices: Water:

Soft drinks: Other:

Do you suffer from food allergies? Yes  No  Bingeing? Yes  No 

Overeating? Yes  No 

Do you suffer from indigestion or heartburn? Yes  No 

Do you smoke? No  Yes  How many per day?

Do you drink alcohol? Light  Medium  Heavy  Units per week

Do you take any non-prescription medications?

If so, what?

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Do you suffer from Dermatitis: Yes  No  Acne: Yes  No  Eczema: Yes  No 

Psoriasis: Yes  No  Allergies: Yes  No  Hay Fever: Yes  No 
Asthma: Yes  No 

Have you ever had any form of therapy treatment before? Yes  No 
If yes, what type and for what reason?

Is there anything relating to your health or requirements that you would like the therapist to
be aware of?

Any Other Information:

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The information provided in this form is privilege and is treated with the strictest of
confidence.

Clients Signature:
Date:
Therapist Signature:
Date:

Client to be offered CBT: Yes \ No

Treatment sessions offered:
Treatment
Offered:

Any Other Information:

CONSENT TO TREATMENT

This form should be used for clients, over 16 who can consent to allow treatment upon
their person.
I declare that the information I have given is correct and as far as I am aware I
can undertake treatments. I have been informed about the CBT process and with
this knowledge am willing and happy to proceed with treatment.
I, Consent to receiving treatments.

………………………………………. (Client Signature) ......................................... (Date)

…………………………………………(Therapist)
…………………………………………(Signature)
…………………………….(Date)

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Very important to the successful use and outcome of CBT is the ability to develop
a formulation – also known as a case conceptualisation map.

A formulation is basically an individualised picture that helps the therapist/

practitioner to understand and explain the client‟s presenting issue or problem.

It is worth remembering that there is no one „correct‟ way of putting together a

formulation, they differ from therapist to therapist and are dependant on the
training the therapist received, whether they are also life coaching or using NLP
as a treatment alongside CBT etc.

However, all formulations share common core features and these are:

A vivid description of the current presenting problem or issue.

An account of how and also why these problems may have developed.

A breakdown to the main processes that keep the problem or issue ongoing.

Whilst it may appear to be common sense that a picture of the issue is clarified
before any decision re: treatment or processes is decided upon it is amazing how
sometimes the easiest most obvious things are overlooked.

The main benefits for making a formulation prior to treatment are:

The fact that the formulation and its process help both therapist and client to
understand the problems, so that any confusion or misunderstanding over the
symptoms that a client may be presenting can often begin to make almost
immediate sense.

A formulation can also help to deal with the feelings of failure and demoralisation
which frequently presents with clients who wish to undertake CBT treatment.

It can also prove highly useful for the therapist when faced with a complex or
really difficult client or scenario. A completed formulation will often bridge the
CBT theory regarding how the problem developed and continues and how it
relates to the client‟s experience.

The formulation can provide a shared rationale and actual guide for the type of
therapy which may be used to combat the client‟s issue.

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As well as highlighting the most appropriate therapy for the situation, a

formulation will also focus on the situation and literally come up with the list of
issues to be addressed and even how they can be broken down into smaller more
manageable therapeutic tasks and goals.

It can also show the client why a particular therapy would be more suitable for
their issue instead of just taking the therapist‟s word – after all, the CBT process
relies heavily on client work, input and more importantly, understanding
throughout the process.

The formulation can be an excellent way of opening up new ways of thinking

about the situation by giving the client a different perspective on their issue and
a different view of their symptoms – this is really key to the CBT process as many
clients will first present for treatment feeling scared, self-critical, frustrated, angry
or even threatened. By looking at the issue from other perspectives, this can
greatly support the client in making the changes that they need to by learning to
tackle the problem in a totally different way.

The formulation can also, very importantly, help the therapist to understand and
even possibly predict difficulties, challenges or blockages within the therapeutic
process or relationship.

By being forewarned they can have contingency plans ready to counter the
difficulties that may arise and, in effect, manage the difficulties much better.

Below is an example of a Formulation Worksheet that can be used:

Ask the client to complete the questions below, taking time to focus on one
question at a time.

Client Formulation Sheet.

1. What is my current problem?

My current problem is :

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When did I first notice this problem had or was developing?

I first noticed this problem in:

How do I think that this problem developed?

I think that this problem developed because:

What is keeping this problem going for me?

I think this problem continues to go on for me because:

That thoughts, ideas or beliefs do I have that actually support this

problem?

The thoughts, ideas or beliefs that I hold to support this problem are:

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What reactions do I have in association with these thoughts and my

presenting problem?

Emotional Reactions – How I feel emotionally:

Physical Reactions – How do I feel physically:

Behavioural Reactions – How do I behave:

Can you see any link between the thoughts, behaviours, feelings and
physical symptoms you are experiencing?

The links are:

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Can you identify what is continuing to maintain the problem for you –
what fuels it?

The problem is continuing because:

Can you identify any type of personal meaning that this has for you?

This means to me :

Can you work out where this personal meaning may have come from?

It stems from:

Clarifying the Problem

Basically, if the formulation is correctly and fully completed, it can actually

clarify the problem or presenting issue which in CBT is vital before treatment can
commence.
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There are other therapies that concentrate on finding out the issues as the
treatment sessions continue but the nature of CBT does not work well with this
therapy theory.

Below is an example of how this might look in a client scenario.

Client Formulation Sheet.

What is my current problem? I can‟t get a job.

My current problem is: I keep applying for jobs, getting to the

interview stage but never actually get offered the job.
It has happened to me 4 times this month already.

When did I first notice this problem had or was developing? A while
back, I guess.

I first noticed this problem in: After I was made redundant from my last
proper job last year – since then I get to the interview, do and say all the
right things, but always get a thank-you but no thank-you letter the next
day.

How do I think that this problem developed? Because it seems that I

will never have another job ever again.

I think that this problem developed because:

Because the job I was made redundant from was my first proper job, it
was the first job I applied for after university and because I was really
happy there, I never felt the need to go job hunting.

What is keeping this problem going for me? Because I keep failing.

I think this problem continues to go on for me because:

I have lost my confidence, I now go to each interview knowing I am not
going to get the job, so I guess I don‟t make as much effort as I should
because what‟s the point?

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What thoughts, ideas or beliefs do I have that actually support this

problem? I just feel it deep down.

The thoughts, ideas or beliefs that I hold to support this problem are:
I think I am now unemployable, my failure to secure a job backs this up
for me, my partner says it would be easier and less upsetting if I just went
on job seekers allowance for a while and stopped trying for a job.
I must be unemployable – if I wasn‟t, I wouldn‟t have been made
redundant.

What reactions do I have in association with these thoughts and my

presenting problem?
Emotional Reactions – How I feel emotionally:

Like a failure.
Tearful.
Like I can‟t be bothered to get up in the morning.
That whatever I do won‟t work ever.

Physical Reactions – How do I feel physically:

Sick.
Tired.
I‟m getting lots of stress headaches recently.
I‟ve come down with colds, tummy bugs and rashes ever since I got made
redundant.
Can‟t sleep at night.

Behavioural Reactions – How do I behave:

I‟m picking fights with my family and friends more.
I‟m horrible to my partner.
I‟ve been drinking more alcohol.
Avoiding my old work colleagues because I feel such a failure.

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Can you see any link between the thoughts, behaviours, feelings and
physical symptoms you are experiencing?
Some. I guess.

The links are: When I start focusing on the lack of job thing, I start to
feel really fed up and rejected, then I start feeling unwell, which just
makes me feel more fed up, which makes me think more about the lack of
job – it‟s like a vicious circle.

Can you identify what is continuing to maintain the problem for you
– what fuels it?
Because no-one will give me a job.

The problem is continuing because:

Because I think no-one will give me a job, I‟m really beginning to believe
that that‟s the case and the more I think like that and not change my job
seeking tactics, the more its going to happen.

Can you identify any type of personal meaning that this has for you?
It does ring a few bells.

This means to me :
My father was always out of work, he‟d get a job, lose it, drink some
more, get another job, lose that one and end up back on benefits.

Can you work out where this personal meaning may have come
from?

My childhood.

It stems from:
My dad being such a loser – I‟m so scared I‟ll end up like him, living in a
bed-sit, on handouts, no friends, no partner because mum left him and ill
from too much alcohol.

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As you can see, by gradually working through the formulation questions, it

becomes very apparent that the lack of job is not actually what is holding the
client back but their actual fear of failing like their parent did.

Good questions to use to gain more information for the formulation are:

 What is the life situation that is causing you the problem?

 Is it something that has happened recently?

 Looking back into your past, does it stem from then?

 How does that make you feel? Physically? Emotionally? Behaviourally?

Spiritually?

 How do you feel about yourself?

 How do you feel about other people in your life?

 How do you feel about the situation?

 How do you feel about the future?

 How do you react when you find yourself in that situation?

 Do you accept the situation?

 What changes do you want to make?

 Are you avoiding the situation?

 How will you know when you have changed the situation you your
satisfaction?

Client Confidentiality and Consent

When the consultation and formulation have been completed, the sessions will
need to be recorded and the information kept safely.

The sessions and subsequent end of treatment discharge can be kept on the forms

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found below:

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CBT Session Meeting Sheet

Name:
(Client‟s)

Date:
(Date of session)

Session:
(Session nos:)

Reason for CBT session/sessions:

(Presenting issues identified)

Work to be addressed:
(Issues to be focused on for this session)

Recap from previous session/ if applicable:

(Highlights from client & Practitioner from previous session, any breakthroughs
etc)

Agreed homework from this session:

(Work agreed upon by client & Practitioner)

Date of next session:

(Next session planned)

Signature – Client:

Signature – CBT Practitioner:

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CBT
DISCHARGE FORM.

Clients name:

Referred By:

Treatment Start Date:

Treatment Sessions:

Treatment Conclusion Date:

Reason for Treatment:

Summary of Treatments given:

Aftercare/ Further work to be done advice:

Any Other Comments:

Seen By:

Discharge Date:

Signature:

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 Cognitive Behavioural Therapy

As a professional practitioner, you need to understand what it means to act

ethically at all times.

Two important aspects of this are maintaining client confidentiality and seeking
consent.

Confidentiality means that the client can trust you not to reveal their personal
details to any other person.

As a Therapist, you will need to have quite intensive information and history of
the client.

It is not acceptable to reveal anything that a client has told you to any other
person without their express permission.

This means not discussing information about them with anyone, including:

1) Friends
2) Family
3) Other clients
4) Other practitioners you may work with or alongside
5) Their GP (without their consent).

Clients are far more likely to trust you if they are sure that what they tell you
will remain confidential.

This, in turn, has a positive effect on the treatment or service you offer them,
and the loyalty they will have for you.

Keeping client confidentiality also applies to any notes you take in consultations
with your clients.

If you do keep a record of any personal information, you should store your files
in a secure box or filing cabinet under lock and key.

Confidentiality applies both to information that you ask a client for and the
information they chose to tell you.

The obligation to maintain confidentiality continues even after the death of a

client.

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When you can discuss information about a client

There are a few occasions when you may need to disclose information about a
client and these include:

1) Your client is under 16 years old and child protection legislation applies.
Note that parental consent is required to treat a minor and parents should
be given the opportunity to remain in the room during treatment.
2) You need to check out with a GP whether it is safe to treat a person. In this
case, you would seek the client‟s written permission before contacting the
GP.
3) You suspect serious professional misconduct on the part of another
professional. Again, you would seek written permission from the client
before proceeding.
4) You want to use a client‟s details as part of your own professional
supervision. Some therapists have supervision with more experienced
practitioners or external counsellors as good practice. Whilst it is not
currently law that as a therapist you must have Professional Supervision, I
can advise that it is a very useful part of your work and professional
development. As before, you should seek written permission from your
client before bringing their information and case to supervision.

© Sue Etherden 2008

The right of Sue Etherden to be identified as the author of this work has
been asserted by her in accordance with the Copyright, Designs and
Patents Act 1988.

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QUESTIONS ON LESSON THREE

Q1. What is your understanding of keeping confidential records - Data

Protection?

Q2. Suggest 6 questions you could ask to gain further information whilst
using the formulation process?

Q3. What is formulation also known as?

Q4. State 3 main benefits for making a formulation prior to treatment?

Q5. What will you need to update regarding your client information?

Q6. In what circumstances can you disclose information legally?

Q7. Design a CBT meeting sheet that you could use as a

therapist/practitioner?

Q8. Explain how a formulation could help the therapist to understand

and even possibly predict difficulties, challenges or blockages within
the therapeutic process or relationship?

Q9. What are the shared common core features of formulations?

Q10. Briefly, what is your understanding of client confidentiality?

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Return your answers to either:

[email protected]

Do not send any attachments; just type your answers into the body of the
email, some formatting required.

Please complete the subject box of every email exactly as follows

(This has to be machine read and is Case Sensitive):

Your Name – CBT (tutored) – Lesson Number

Leave at least one blank line between each answer.

Don’t forget to keep a copy for your own records

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