Chapter 4: Assessment and Formulation

Question 1

CBT Formulation

Answer 1

An individualized picture that helps us to describe understand and explain a client’s problems :

• why and how these problems might have developed
• key maintaining processes hypothesized to keep problems going

Question 2

Benefits of making a CBT Formulation

Answer 2

• Helps the client and therapist make sense of their symptoms
• Acts as a bridge between CBT theories about the problem and the individual client’s experience
• Provides a shared rationale
• a guide for therapy
• opening up new ways of thinking;
• Can help the therapist to predict difficulties in therapy or relationship

Question 3

Focus on Current Maintenance Processes - why?

Answer 3

Bc the processes that start a problem are not necessarily the same as the processes that keep it going

Easrier to get evidence about current processes than past ones

It is easier to change maintenance processes that are happening here and now than to change developmental processes

Eg if want to put out fire no point looking for the match

Question 4

Importance of Developmental History

Answer 4

to answer the question, how did I get here?

to identify original causes in order to prevent them again future eg find matches

an important part of the problem is inherently in the past. (PTSD or consequences of childhood trauma)

Question 5

Process of CBT Assessment

GAD MT
DMAT

Answer 5

1. Gather information
2. analyse using CBT theory,
3. develop and modify hypotheses about processes
4. Tentative ideas about clients formulation

Always building and testing hypotheses as information comes to light and if supports then become part of the formulation if not then modified and seek further information

THEN

1. Discuss and modify with client if necessary
2. Agree on formulation
3. Treatment plans
   This is the treatment phase - note that may need to modify formulation and acquire info as treatment proceeds as new information comes to light

Question 6

Cognitions

Answer 6

Words or images that go throught the client’s mind when he has the problem

What goes through your mind when…. you are feeling…
What went through your mind just now?
Evoke sensations to get to thoughts

Question 7

Behavior - questions to elicit?

Answer 7

What the client does, actions that are outwardly visible

What do you now do because of the problem which you did not used to do?

-What have you stopped doing due to the problem?

Question 8

Go Through a Recent Event ask what change first noticed?

Answer 8

Elicit what happened in each of the four systems:

What went through your mind when that happened?
How did that make you feel?
Did you notice any changes in bodily sensations?
What did you do?
What was the next thing that happened? etc

Question 9

Triggers

Answer 9

Factors that make the problem more or less likely to

occur

Question 10

Modifiers

Answer 10

Contextual factors that impact the severity of the problem when it does occur

Question 11

Situational Variables

Answer 11

Are there specific situations, objects or places that make a difference?

Question 12

Social/Interpersonal Variables

Answer 12

Are there particular people who make a difference?
The number of people around?
Particular kinds of people?

Question 13

Cognitive Variables

Answer 13

Are there particular kinds or topics of thought which tend to trigger problems?

Question 14

Behavioral Variables

Answer 14

Does the problem occur when the client or other people are doing specific activities

Question 15

Physiological Variables

Answer 15

Is the problem affected by taking alcohol or drugs?
Are the problems more likely when the person is tense, tired or hungry?
Does a woman’s menstrual cycle affect the problem?

Question 16

Affective Variables

Answer 16

Is a problem worse when the person is bored, depressed, or upset?

Question 17

Usefulness of Triggers and Modifiers

Answer 17

Themes and clues about beliefs and maintaining processes (eg social situation may be fear of evaluation)

Can prompt further questions that can help to confirm or refute the initial guesses

Helpful in identifying targets for treatment or in planning interventions

Question 18

Questions for Consequences

Answer 18

What impact has the problem had on the client’s life?

• How has his life changed because of the problem?
• How have others responded to the problem?
• What coping strategies have he tried, and how successful has he been?
• Is he using either prescribed medication or other substances to help him cope?

Question 19

Vicious Cycles/Feedback Loops

Answer 19

Cycles in which the original thought, behavior, afective or physiological response gives rise to effects that ultimately feedback to the original symptom so as to maintain or even worsen it

Question 20

Safety Behaviors Fear

Answer 20

Fear of some threat/disaster > safety behaviour > failure to dis-confirm threat

Eg. Fear of illness or harm > some behaviour performed to prevent the disaster > Nothing bad happens attributed to the safety behaviour rather than changing the view of the threat

Common in anxiety - fear pf collapse > hold on to shopping trolley so not fall over in supermarket.

e.g. waving arms to scare dragons away

Question 21

Escape/Avoidance Fear

Answer 21

Fear of situation or object > escape/avoidance > failure to dis-confirm fear beliefs

Eg Fear situation/object> client avoids or escapes> does not learn coping or expose beliefs to dis-confirmation

Eg common in anxiety

Question 22

Reduction of Activity

Answer 22

Depressed mood > negative thoughts > reduced activity > loss of positive rewards > depressed mood

Eg Low mood and thoughts that activities will be boring or pointless > reduced social and activity > loss of activities that use to give pleasure, achievement or connection > lower mood

common in depression

Question 23

Catastrophic Misinterpretation of symptoms

Answer 23

Bodily symptoms of anxiety > misinterpretation as dangerous > increased anxiety > Bodily symptoms of anxiety

Breathing difficulties or HR Increased from anxiety > misinterprets “this is a heart attack” > increased anxiety and symptoms increased

Common in panic disorder

Question 24

Scanning or hyper-vigilance worry

Answer 24

Worry about illness > scanning and checking > sensation produced/noticed > worry about illness maintained

Eg worry that might get sick > scanning or checking> notice symptoms > confirms worry

Common in health Anxiety or PTSD

Question 25

Self-Fulfilling beliefs

Answer 25

Negative beliefs about others (wont like or hostile) > change behaviour towards others > Elicits change in behaviour from others towards us (stop social invites or hostility) > confirmation of predictions > negative beliefs about others

Question 26

Performance Anxiety worry

Answer 26

Worry about performance > anxiety disrupts performance > confirms beliefs about poor performance > maintains worry about performance

Common in social anxiety and erectile dysfunction;

Question 27

Fear of Fear (anxiety)

Answer 27

Anxiety (any cause) > anxiety symptoms considered aversive > develop anticipatory fears about becoming anxious again > anxiety maintained

Common in Panic

Question 28

Perfectionism beliefs

Answer 28

Negative beliefs about self > Set high standards to compensate> impossible to achieve /fails > maintains negative self beliefs

Maintains worthlessness - OCD and SAS

Question 29

Short Term Rewards

Answer 29

Problem behaviour (eg substance) > short term reward increases positive feelings. Long term consequences are maintained

Common in substance abuse, eating disorder, aggressive behavior, escape and avoidance.

We are more shaped to respond to short term consequences

Question 30

Precipitants or critical incident

Answer 30

Events or situations that are closely associated with the actual onset of a problem or with a significant worsening

happened by definition in the past, typically happen once or at lest a limited number of times

Question 31

Triggers

Answer 31

Continues to operate in the present; can happen many times per day.

Question 32

Modifying Factors

Answer 32

Changes in relationships, major role transitions, getting married or having one’s children leaving home; changes in responsibilities

Question 33

Good CBT Technique

Answer 33

Pause frequently to summarize your understanding of what the client has told you and to ask for their feedback on whether you have got it right;

Gives therapist time to reflect and think about where to go next
Reduce risk of misunderstanding
Conveys message that the client is an active partner and therapist is not all-wise and all knowing

Question 34

Making Formulations

Answer 34

Not too fast, not too slow - two session assessment
Diagrams - Draw them on paper or a whiteboard (VBPPMT)
Vulnerability
Beliefs
Precipitants
Problems - emotion, physiology, cognition & behavior
Maintenance
Treatment

Question 35

Suitability for short term CBT

Answer 35

Can access NATs in session
Can differentiate, different emotions;
relates well to the cognitive model;
Accepts responsibility for change;
can form a collaborative therapeutic alliance
problems of relatively acute onset and history;
Shows ability to work on one issue at a time in a relatively focused way
Reasonably optimistic about therapy

Question 36

Possible Problems During Assessment

Answer 36

Problems for the therapist (Must recognize quickly when they’re asking the right questions)

Becoming used to the problem he no longer notices factors you are trying to assess;

Avoidance or other safety behaviors have become so effective that the client no longer experiences negative thoughts and cannot report them;

client finds it difficult to access or report thoughts and emotions;
fear of therapist’s reactions; Other feared consequences of reporting the symptoms openly)

Question 37

Possible Problems in Making Formulations

Answer 37

avoid assumption that clients intend the consequences of their behavior
Censoring the Formulation
Spaghetti Junction
Tunnel Vision

Question 38

Hot Cross Bun

Answer 38

Interaction among 4 dimensions: Behaviors, Physiology, Thoughts, and Emotions

Question 39

5 Aspect model in assessment for situational analysis

Answer 39

Trigger (int/ext) > core belief > NAT<> mood <> Behavour <> physiology <> cognition

In a belief driven formulation there is a core belief that is activated after the trigger and before the NAT

Question 40

Downward arrow

Answer 40

Technique identify underlying assumptions and core beliefs that underlie NAT’s

If that were true… why would that upset you, what would be so bad about that or what would that mean to you

Question 41

Maintenance cycles in Depression`

Answer 41

Depressed mood > leads to symptoms >

1. SXS> negative self views > lowers mood
2. SXS> Reduced activity > loss of pleasure achievement > low mood
3. SXS> Reduced coping problem solving > nothing changes > increased hopelessness > depressed mood