Wk 8 - Complex Problems Flashcards
What do we mean by complex problems in clinical contexts? (x5)
Interrelationship of various problems, that might be reinforcing each other
• Difficulties in where to intervene
Covers:
o Several presenting problems
o Longstanding difficulties that don’t fit any specific diagnosis but cause significant distress or impairment
o Personality disorders
Describe the biographical details of ‘Alex’ (complex problems case study) (x6)
32 year old woman Single, no children Lived in house with beloved dog and overseas students Worked fulltime in events management Catholic faith and principles Charity work
What precipitating events of ‘Alex’ (complex problems case study) (x7)
Extremely high arousal and distress
• Very difficult for her to articulate what was actually going on
History of being stalked over a 5 year period
Came to feel very unsafe
Reported to police
Culminating in sexual assault (2003)
Perpetrator a known and trusted neighbour
What was the main diagnosis of Alex’ (complex problems case study) (x8)
PTSD - from trauma outside normal experience Re-experiencing (intrusive images, nightmares) is common Physiological arousal (tension and anger, HR, shallow breathing, sleep disturbance, hypervigilance, GIT disturbance) (a) Hyper vigilance – constant scanning for threats, easily startled (b) Gastro-intestinal disturbances Avoidance (places, talking about it, intimate relationships) Sexual problems with ex-boyfriend leading to break-up – avoidance of sex Ran into perpetrator recently and vomited – trigger for getting help
What were additional problems of ‘Alex’ (complex problems case study) (x7)
Traits of histrionic personality
o Always immaculate presentation
o Excessive emotionality – like she was acting in her own drama
o Attention-seeking
o High need for approval
o Advanced social skills, persuasion
Alex and mother work together daily but Alex withholds information and attention from her mother
What was ‘Alex’s’ relationship history? (x4)
Series of short-term relationships with men
Very romantic idea of relationships – the perfect match is out there!
Avoidant style – wouldn’t sort things out in a relationship, just left
Relationship with John ended because of unmet emotional needs on both sides
What was the five-axis diagnosis of ‘Alex’
Axis I: 309.81 PTSD - chronic
Axis II: Traits of histrionic personality
Axis III: Loss of left lung function; history of serious airway problems, Crohn’s disease.
Axis IV: Relationship problems with mother, and (later) boyfriend
GAF: 55 at intake - general functioning still surprisingly going to work etc, but avoiding a lot of things, had little support
What does a just world view entail? (x2)
And what effect does trauma have on this? (x3)
Good things happen to good people and bad things happen to bad people – the stuff of fairy tales and nursery rhymes
Shatters such a view, so they do one of two things…
Over-accommodation
Assimilation
What is over-accommodation? (x1 plus x3 e.g. thoughts)
Changing your beliefs to accommodate the new experience, but over generalising
The world is an unfair, unsafe place
All men are out to harm me
I am damaged goods, nothing good will happen to me
What is assimilation? (x plus x1 e.g. thought process)
Changing the reality of her experience to fit her pre-existing beliefs
The world is a fair place, bad things happen to bad people and good things happen to good people, therefore, it didn’t happen. I must have imagined it; or I must have deserved it
What might be the target of early Stabilisation sessions? (from Alex and complex problems) (x6)
Look for key distortions (accommodation, assimilation), and look for ways to address them
Education about physiological arousal
Relaxation strategies – breathing, PMR
She had stopped walking much-loved dog through fear, so starting again was exposure therapy
Imagery of safe place – her Nana’s as a child
Focus on strengths and positives
What was Resick and Schtick’s Cognitive processing therapy developed for? (x1)
What does it entail? (x7)
Developed specifically for victims of rape, considered to be less personally confronting Gradual exposure and emotional processing using written and verbal narratives: o Impact statement o Self-blame or “undoing” o Safety o Trust o Power / control o Self esteem
Why did Dr Dingle choose Cognitive Processing Therapy over other PTSD treatments for ‘Alex’? (x3)
Such as eg Foa’s repeated exposure –
Due to high levels of physiological arousal and potential for overwhelming the client’s psychological resources.
Also help relationship functioning - linking sexual assault and impact on ability to relate to others, build trust, set reasonable boundaries, etc
How did Dr Dingle use Imagery and Music in ‘Alex’s’ treatment? (x3 and x2)
Image of stalker’s face frequently intrusive
o Used imagery processing (eg Hackman)
o Created image of a small rodent that she could kick away with her sturdy boots
Use of theme songs to improve mood and self confidence, eg:
o “All Fired Up” – Pat Benetar
What are three types of therapy that fall under the banner of ‘Third wave’ of cognitive therapies?
Mindfulness – a Buddhist philosophy
ACT – Acceptance & Commitment Therapy
DBT – dialectical behavior therapy also includes mindfulness
What is the central tenet of the Third wave of cognitive therapies?
Which is based on realisation that… (x2)
‘thoughts are not facts’
Identifying and challenging your thoughts of cognitive behavioural therapy – some have argued that such a focus on them can actually worsen them
