Orthodontic Assessment

**CBT Session Note** Patient Name: Sarah Jones, 1 November 2024, Session number: 3 Therapist: Dr. Emily Carter Session focus Low mood and social anxiety Client update - Mood and symptom check-in: Client reported a low mood, rating her distress level at 6/10. She also reported increased social anxiety, particularly in anticipation of upcoming social events. - Recent events: Client reported feeling overwhelmed by work deadlines and a recent disagreement with a friend, which triggered feelings of inadequacy. - Homework review: Client completed the thought record as assigned. She identified several negative automatic thoughts related to her social anxiety. She did not complete the behavioural experiment due to feeling overwhelmed. Agenda - "Agenda set collaboratively": Yes, the agenda items included reviewing the thought record, exploring social anxiety triggers, and planning a small behavioural experiment. - Items prioritised: Review of thought record, identification of social anxiety triggers, and planning a small behavioural experiment. - Time managed well: The agenda was followed, and the session ended on time. Cognitive interventions - Socratic questioning used: Yes, key distortions and beliefs explored included the client's belief that she was unlikeable and that others were judging her. Evidence of cognitive shifts was observed as the client began to question the validity of these thoughts. - "Guided discovery": Identifying automatic thoughts related to social anxiety and exploring evidence for and against these thoughts. - Thought records / experiments: The client completed a thought record, identifying the situation (upcoming social event), the thought ("I'm going to embarrass myself"), the feeling (anxiety), and the evidence for and against the thought. This led to a cognitive shift as she began to challenge the thought. Behavioural interventions - Behavioural experiment or activity scheduling: A small behavioural experiment was planned for the coming week, involving attending a small social gathering and observing her thoughts and feelings. - "Homework planning": Yes, the behavioural experiment was collaboratively agreed upon and considered achievable. The client was encouraged to focus on observing her thoughts and feelings rather than trying to change them. - Avoidance or safety behaviours addressed: The client's tendency to avoid social situations was discussed, and the behavioural experiment was designed to address this avoidance. Therapeutic process - Collaboration and structure: High engagement and collaborative approach. - Use of formulation: The session referred to the cognitive model, drawing links between thoughts, feelings, and behaviours. - Therapist style: "Empathic", "structured", and "collaborative". - Client insight or shifts: The client expressed a greater understanding of the link between her thoughts and feelings, and she showed a willingness to challenge her negative thoughts. Homework - Task assigned: Complete the behavioural experiment and continue to monitor thoughts and feelings. - Rationale shared: Yes, the client understood that the experiment would help her challenge her negative thoughts and reduce her anxiety. - Troubleshooting discussed: The client anticipated some difficulty with the experiment, and we discussed strategies for managing her anxiety. Next session - Planned focus: Review the results of the behavioural experiment and continue to explore social anxiety triggers. - Any adaptations: No adaptations were needed. Risk and safety - Risk check: No suicidal ideation or self-harm reported. - Protective factors discussed: The client identified her supportive family and friends as protective factors. - Action taken: None.