Chapter 4: Assessment and Formulation

Question 1

Case Conceptualization

Answer 1

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

Question 2

CBT Formulation

Answer 2

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

Question 3

Benefits of making a CBT Formulation

Answer 3

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

Question 4

Focus on Current Maintenance Processes

Answer 4

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

Question 5

Importance of Developmental History

Answer 5

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

Question 6

Process of CBT Assessment

Answer 6

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

Question 7

Break Presenting Problems into Systems

Answer 7

Cognitions
Emotions/Affect
Behavior
Physiological Changes/Bodily Symptoms

Question 8

Cognitions

Answer 8

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?

Question 9

Hot Thoughts

Answer 9

Thoughts accessed whilst they are generating strong emotions

Question 10

Emotions or affect

Answer 10

The Client’s emotional experience

Question 11

Emotion Vs. Thoughts

Answer 11

Emotion can be described in one word. If it is more than one word, it is a thought

Question 12

Behavior

Answer 12

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?

Question 13

Physiological Changes/Bodily Symptoms

Answer 13

Symptoms of autonomic arousal in anxiety

Question 14

Go Through a Recent Occasion

Answer 14

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?

Question 15

Triggers

Answer 15

Factors that make the problem more or less likely to occur

Question 16

Modifiers

Answer 16

Contextual factors that make a difference to how severe the problem is when it does occur

Question 17

Factors which can operate as triggers or modifiers

Answer 17

Situational variables
Social/Interpersonal variables
Cognitive Variables
Behavioral Variables
Physiological Variables
Affective Variables

Question 18

Situational Variables

Answer 18

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

Question 19

Social/Interpersonal Variables

Answer 19

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

Question 20

Cognitive Variables

Answer 20

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

Question 21

Behavioral Variables

Answer 21

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

Question 22

Physiological Variables

Answer 22

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 23

Affective Variables

Answer 23

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

Question 24

Usefulness of Triggers and Modifiers

Answer 24

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

Question 25

Consequences

Answer 25

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?

Question 26

Vicious Cycles/Feedback Loops

Answer 26

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 27

Maintenance Patterns

Answer 27

Psychological processes that keep a problem going;

Question 28

Safety Behaviors

Answer 28

Steps taken to do something which the client believes protects them from whatever threat it is that they fear

Question 29

Escape/Avoidance

Answer 29

Common form of safety behavior; near universal prevalence in anxiety problems and unhelpfulness to clients

Question 30

Reduction of Activity

Answer 30

Maintaining process that is common in depression

Question 31

Catastrophic Misinterpretation

Answer 31

Central cognitive process in panic disorder

Question 32

Scanning or hypervigilance

Answer 32

Common in PTSD

Question 33

Self-Fulfilling Prophecies

Answer 33

Process through which people with negative beliefs about others’ attitudes towards them may elicit reactions that appear to conform those beliefs

Question 34

Performance Anxiety

Answer 34

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

Question 35

Fear of Fear

Answer 35

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

Question 36

Perfectionism

Answer 36

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

Question 37

Short Term Rewards

Answer 37

obvious in many problems of substance abuse, some forms of eating disorder, aggressive behavior, escapte and avoidance

Question 38

Looking at the past

Answer 38

Identify vulnerability factors, precipitating factors, and modifying factors

Question 39

Vulnerability factors

Answer 39

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

Question 40

Precipitants

Answer 40

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

Question 41

Triggers

Answer 41

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

Question 42

Modifying Factors

Answer 42

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

Question 43

Good CBT Technique

Answer 43

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

Question 44

Making Formulations

Answer 44

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

Question 45

Suitability for CBT

Answer 45

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

Question 46

Trial Period to Determine if CBT will Work

Answer 46

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

Question 47

Possible Problems During Assessment

Answer 47

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)

Question 48

Possible Problems in Making Formulations

Answer 48

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

Question 49

Hot Cross Bun

Answer 49

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