Client assessment

A variety of assessment procedures are used to understand the client’s therapeutic needs, to determine which CBT techniques to use in treatment, and to measure progress. As with almost all forms of psychotherapy, the clinical interview is an important tool for therapists who use CBT. In addition to the usual topics covered during the interview (e.g., history of the presenting problem, personal and family history, etc.), CBT therapists inquire about the types of behavioral excesses and deficits that are associated with the client’s difficulties, the triggers and consequences of problem behaviors, and the types of cognitions that are associated with negative mood states such as anxiety, depression, and anger. Often, semi-structured interviews are used to ensure a standardized approach to assessment that is unlikely to accidentally miss important features of the problem.

Direct behavioral observation involves observing a client in a relevant situation and noting behaviors and responses of interest. For example, when treating social anxiety disorder using CBT, therapists may first administer a behavioral approach test (BAT), in which the client confronts a feared situation (e.g., a casual conversation with a stranger, or a brief presentation). During the BAT, the therapist has the opportunity to observe the client in order to note any skill deficits and to observe any avoidance or safety behaviours that are used during the test. After the BAT, clients typically report on the severity of their anxiety and on any anxious thoughts that occurred during the exercise. Behavioral observation has the advantage, over other forms of assessment, of being able to identify behaviors or other features of a problem of which a client may be unaware.

Monitoring diaries are forms that clients complete on a regular basis to measure relevant symptoms or to monitor their use of particular CBT strategies. For example, in the treatment of depression it is common to have clients monitor their depressive thoughts and to use cognitive diaries to challenge their patterns of negative thinking. An advantage of monitoring diaries is that they avoid problems of retrospective recall bias. By having clients report on their symptoms as they occur, they are more likely to provide an accurate account of the frequency and severity of their symptoms than they might be if they were simply trying to re-create the memory of the symptoms while sitting in the therapist’s office several days or weeks later.

Numerous standardized scales exist for measuring the most important features of almost every diagnostic category. For anxiety disorders alone, more than 200 empirically supported scales were in use in the early 21st century. For example, in the case of panic disorder and agoraphobia, scales measure the frequency of panic attack symptoms, the severity of agoraphobic avoidance, and the extent to which the client is fearful of panic-related sensations (a hallmark feature of panic disorder). Information obtained on self-report scales can be used to help select targets or goals for treatment as well as to select the most appropriate strategies for dealing with the problem.