Chapter 4: Assessment and Formulation Flashcards
Case Conceptualization
An individualized picture that helps us to understand and explain a client’s problems
CBT Formulation
Uses the CBT model to develop
a description of the current problem (s)
an account of why and how these problems might have developed
an analysis of key maintaining processes hypothesized to keep problems going
Benefits of making a CBT Formulation
Helps client and therapist understand problems so that what may present as a baffling collection of random symptoms moves from chaotic confusion to something that makes sense; can begin to combat demoralization common to clients at initial presentation
Acts as a bridge between CBT theories about problem development and maintenance and the individual client’s experience
Provides a shared rationale and guide for the therapy which may follow
Begins the process of opening up new ways of thinking;
Can help the therapist to understand, or even predict, difficulties in therapy or in the therapeutic relationship
Focus on Current Maintenance Processes
The processes that start a problem are not necessarily the same as the processes that keep it going; once a problem has begun, maintenance processes can take on a life of their own and keep a problem going, even if the original cause has long since disappeared
It is generally easier to get clear evidence about current processes that in is about original causes, which may have happened many years ago
It is easier to change maintenance processes that are happening here and now than to change developmental processes, which by definition are in the past
Importance of Developmental History
Essential if one is to answer the question, how did I get here?
It may be useful to identify original causes in order to prevent their operating again in the future
There are some difficulties where an important part of the problem is inherently in the past. (PTSD or consequences of childhood trauma; schema-focused therapy for people with personality disorders or other complex problems
Process of CBT Assessment
Primarily to arrive at a formulation which is agreed as satisfactory by both client and therapist and which serve the purposes outlined
Make sense of information coming from client
Build ideas about what processes might be important in the formulation
Further assessment is aimed at teating hypotheses
If further evidence seems to suport ypothesis, it may become part of the formulation; if not, then the hypothesis will need to be modified and further evidence will be sought
Process continues until the therapist feels there is enough of a formulation to begin discussing it with the client
Working draft formulation is agreed
Further information that emerges during treatment may lead to modifications or additions to the formulation
Break Presenting Problems into Systems
Cognitions
Emotions/Affect
Behavior
Physiological Changes/Bodily Symptoms
Cognitions
Words or images that go throught the client’s mind when he has the problem
What goes through your mind when….
What went through your mind just now?
Hot Thoughts
Thoughts accessed whilst they are generating strong emotions
Emotions or affect
The Client’s emotional experience
Emotion Vs. Thoughts
Emotion can be described in one word. If it is more than one word, it is a thought
Behavior
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 as a result of the problem?
Physiological Changes/Bodily Symptoms
Symptoms of autonomic arousal in anxiety
Go Through a Recent Occasion
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?
Triggers
Factors that make the problem more or less likely to occur
Modifiers
Contextual factors that make a difference to how severe the problem is when it does occur
Factors which can operate as triggers or modifiers
Situational variables Social/Interpersonal variables Cognitive Variables Behavioral Variables Physiological Variables Affective Variables
Situational Variables
Are there specific situations, objects or places that make a difference?
Social/Interpersonal Variables
Are there particular people who make a difference?
The number of people around?
Particular kinds of people?
Cognitive Variables
ARe there particular kinds or topics of thought which tend to trigger problems?
Behavioral Variables
Does the problem occur when the client or other people are doing specific activities
Physiological Variables
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?
Affective Variables
Is a problem worse when the person is bored, depressed, or upset?
Usefulness of Triggers and Modifiers
Gives the therapist useful clues about possible beliefs and maintaining processes, by considering what themes might lie behind the variables discovered
Can prompt further questions that can help to confirm or refute the initial guesses
Helpful in identifying targets for treatment or in planning interventions
Consequences
What impact has the problem had on the client’s life? How has his life changed because of the problem?
How have important others responded to the problem?
What coping strategies has he tried, and how successful has he been?
Is he using either prescribed medication or other substances to help him cope?
Vicious Cycles/Feedback Loops
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
Maintenance Patterns
Psychological processes that keep a problem going;
Safety Behaviors
Steps taken to do something which the client believes protects them from whatever threat it is that they fear
Escape/Avoidance
Common form of safety behavior; near universal prevalence in anxiety problems and unhelpfulness to clients
Reduction of Activity
Maintaining process that is common in depression
Catastrophic Misinterpretation
Central cognitive process in panic disorder
Scanning or hypervigilance
Common in PTSD
Self-Fulfilling Prophecies
Process through which people with negative beliefs about others’ attitudes towards them may elicit reactions that appear to conform those beliefs
Performance Anxiety
Common in social anxiety and male erectile dysfunction; worry that one is not going to be able to perform adequately leads to anxiety which may disrupt performance
Fear of Fear
Arises when people find the experience of anxiety itself so aversive that they develop anticipatory fears about becoming anxious again; detached from outside influences that there is nothing tangible to focus on
Perfectionism
Common pattern in clients with negatie beliefs about their own capacity or worth; the desire to prove onself not completely worthless or incapable which results in such high standards that one can never meet them consistently, and, therefore, the sense of worthlessness is maintained rather than reduced
Short Term Rewards
obvious in many problems of substance abuse, some forms of eating disorder, aggressive behavior, escapte and avoidance
Looking at the past
Identify vulnerability factors, precipitating factors, and modifying factors
Vulnerability factors
Anything in a person’s history which might have made him vulnerable to developing a problem, but which does not by itself necessarily mean that he will develop a problem
Precipitants
Events or situations that actually provoke the onset of a problem; critical incidents; factors that seem to be closely associated with the actual onset of a problem or with a significant worsening of a long-standing problem; happened by definition in the past, typically happen once or at lest a limited number of times
Triggers
Continues to operate in the present; can happen many times per day.
Modifying Factors
Include changes in relationships, major role transitions, getting married or having one’s children leaving home; changes in responsibilities
Good CBT Technique
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 allknowing
Making Formulations
Not too fast, not too slow - two session assessment (first - get as much info as you can; second-make sense of information and develop formulation)
Diagrams - Draw them on paper or a whiteboard
Vulnerability
Beliefs
Precipitants
Problems - emotion, physiology, cognition & behavior
Maintenance
Suitability for CBT
Can access NAT in session
is aware of, and can differentiate, different emotions;
relates well to the cognitive model;
accepts responsibility for change;
can form a good collaborative therapeutic alliance (using evidence from previous relationships);
Has problems of relatively acute onset and history;
Does not show unhelpful security operations
Shows ability to work on one issue at a time in a relatively focused way
Reasonably optimistic about therapy
Trial Period to Determine if CBT will Work
Five or six sessions; client and therapist can evaluate how well CBT fits for this individual; long enough to get an idea of whether CBT seems to be useful
Possible Problems During Assessment
Problems for the therapist (Must recognize quickly when they’re asking the right questions)
Problems for the client (Becoming used to the problem he no longer notices factors you are trying to assess; Avoidance or other safety behaviors have become so effectie 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)
Possible Problems in Making Formulations
Effect is not purpose - avoid assumption that clients necessarily intend (even unconsciously) the consequences of their behavior; most clients are trapped in patterns of thought and behavior that do not help them achieve that goal
Censoring the Formulation - Formulation should be open; happens fairly early on in the relationship, when there may not yet be sufficient trust and confidence to contain conflicts
Spaghetti Junction - No need to include every piece of information you have about a client; make sense of information gathered from the client and explain the key processes involved
Tunnel Vision - fixating too early on a hypothesis and then getting stuck; to test a hypothesis, we have to look for evidence that would refute that hypothesis, not just evidence that supports it
Hot Cross Bun
Interaction among 4 dimensions: Behaviors, Physiology, Thoughts, and Emotions
