Theory to Practice: CBT Progress Note

When asked what subjects they wished they would have covered more in college, some members in our Facebook group for community mental health professionals responded that they would have preferred more training in integrating theory into their practice when working in client’s homes. We know from the research that there is a huge gap between theory and practice (Kazdin, 2001) which can make it confusing to know where to go with a client or what to actually do in session. 

One way to practice your hand at theory is see how theory is integrated in a progress note. Progress notes are the perfect opportunity to practice organizing your thoughts and your interventions around a theoretical orientation. Be sure to check out the last article “Beginner’s Guide to Writing a SOAP Note” if you are new to writing progress notes or could use a refresher. 

In this post, I explored what a SOAP note might look like if the clinician used a cognitive behavioral approach. Cognitive Behavioral Therapy (CBT) is a popular modality due its clear goals and practical techniques not to mention its status as a favored theory with insurance companies. Under the umbrella of behavioral approaches, CBT focuses on the “here and now” and examines the relationship between thoughts, emotions, and behaviors. 

Want more information on CBT and its many iterations? Check out resources here and here as well as the graphic below. 

The following SOAP note was loosely based off of this sample case study. 

Sample CBT SOAP note: 

S : Client reported his stress levels had risen since beginning college and that he was often worried that his peers disliked him. Role-played potential interaction with peers and reviewed client’s thought patterns during exercise. Client reported he felt “dumb” and “boring”. When prompted for evidence of peers' beliefs, client denied behavioral evidence of peer disapproval. Client reported symptoms during role play such as sweating and feeling “breathless”. Reviewed breathing relaxation techniques with worksheet Deep Breathing for Anxiety. Engaged in role-play after deep breathing exercise. Client reported a lessening of anxious symptoms. Reviewed journaling homework with prompt from worksheet to explore mind-body connection of anxiety. 

O : Client presented casually for session in jeans and t-shirt. Client’s mood anxious, affect normal. Client oriented to person, place, time, and situation.

A : Client experiencing anxiety due to distorted negative thoughts related to social interactions. 

P: Review homework and continue to practice social-interaction exposure with relaxation techniques. 

Theory:

1. I noted the negative thoughts and fears that client expressed such as the idea of being disliked by his peers.
2. I had the client roleplay a social interaction to examine potential distortions between thoughts and actual behaviors.
3. I challenged the client to examine the evidence behind his anxious thoughts. Hopefully this exercise will model how he can begin to examine the evidence of his thoughts without prompting from me.
4. In addition to examining his thoughts, a CBT therapist would pay attention to the body’s reactions or behaviors related to anxious thoughts.
5. Due to CBT’s focus on practical solutions, I reviewed deep breathing techniques from this worksheet, an evidence-based tool the client could use to combat anxiety-produced behaviors.
6. Inspired by CBT’s use of exposure therapy, I had the client role-play the anxiety-producing interaction again, this time with the deep breathing tools we had just reviewed.
7. I gave the client journaling homework to a) keep the client engaged in the therapeutic process outside of our sessions and b) use the journal as an assessment tool to examine thoughts/feelings related to anxiety.

Interested in using the worksheet “Deep Breathing for Anxiety” that was discussed in this case study? Check out my Etsy shop for this and other creative worksheets. 

Be sure to check out other SOAP note examples in the Theory to Practice series including a Solution-Focused progress note and a Person-Centered progress note.

References: 

Kazdin, A. E. (2001). Bridging the enormous gaps of theory with therapy research and practice. Journal of Clinical Child & Adolescent Psychology, 30(1), 59-66.