assessment and formulation case presentation
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Assessment and Formulation Case Presentation. Natalie Davies. Alice. Referral information 23 year old female History of depression and self harm whilst at university 3 years ago Depression had returned in the last 3 months, along with thoughts of self harm - PowerPoint PPT PresentationTRANSCRIPT
Assessment and Formulation Case Presentation
Natalie Davies
Alice
Referral information
•23 year old female
•History of depression and self harm whilst at university 3 years ago
•Depression had returned in the last 3 months, along with thoughts of self harm
•Living with father and step-mother, after being evicted from the family home along with her mother and sister
•Prescribed 50mg Lustral (Sertraline)
Presenting Issues
• Depressive symptoms improved however......on further exploration, still occasionally
experiencing:– Low motivation– Tiredness– Social withdrawal– Self-critical thoughts
• DSM –IV criteria
Assessment tools
• IAPT Minimum Data Set– PHQ9: 11 (Moderate)– GAD7: 5 (Mild)– WSAS: 20 (Significant impairment)– Phobia 1: 2– Phobia 2: 1– Phobia 3: 0
• Disorder specific measures
Other factors
• Medication– Sertraline 100mg 6 weeks prior to assessment
• Risk– No thoughts of self harm or suicide (score of 0 on
PHQ9 question 9)– No risk of neglect– No risk of harm to/from others
Hot cross bun (Padesky & Mooney, 1990 )
SituationAt home with
step-mum
Cognitive“what’s the point in
getting up?”Physical
Tired, insomnia, sleeping in the
day
MoodSad
Numb
BehaviourStay in bed, on laptop or watch
TV
Hot cross bun (Padesky & Mooney, 1990)
SituationMeeting
someone new
MoodAnxious
BehaviourTell lots of jokes, say “I sound weird” out
loud
PhysicalButterflies in
stomach, faster hear rate
Cognitive“I want to be
someone different” “I’m not normal”
Predisposing factors
• Father left at age 9
• Mother “stopped caring” at age 11– Home felt “unstable and unsafe”
• Mother harsh and critical towards Alice
Precipitating Events
• Evicted from home, went to live with father and step-mother– Step-mother critical
• First serious relationship ended
Goals Westbrook, Kennerley, & Kirk, 2007
“To feel better about myself and have more self belief “ (Long Term)
Refined in session 2:
•To accept compliments (Short Term)•To do a stand-up comedy gig in London (Medium Term)•To stick up for myself more when my step-mum shouts at me (Medium Term)•To be myself and be more relaxed on dates e.g. telling less jokes (Medium Term)
Longitudinal Formulation (Beck et al, 1979)
Early experiencesDad left when 9 years
Mum became neglectful at 11 years
Core BeliefsI’m unlovableI’m abnormal
Assumptions/RulesI can protect myself from the pain of rejection if I don’t let people get close
People only accept you if you’re normal In order to be accepted I must not show the real me
Compensatory strategiesDon’t let anyone get close
Tell someone everything about me that’s “abnormal” straight awayUse of humour to detract from the “real me”
Critical IncidentBroke up from first serious girlfriendMoved in with Dad and Step-Mum
TriggerDate doesn’t go well, reminder of ex
NATs“It’s because there’s something wrong with me”
“I’ll be alone forever”
Emotion Physical Depressed, Lonely Tired, tearful, low motivation
BehaviourStop going on dates, use humour more in interactions, withdraw from friends
Which model?• Beck et al’s (1979) cognitive model of
depression– identified assumptions and core beliefs– developed as a result of early experiences– rigid assumptions, resistant to change– NATs triggered, which lead to depressed mood
and social withdrawal
Low Self Esteem?– Schemas in cognitive model of depression (Beck et
al, 1979) similar to self esteem i.e. “they are a product of learning and, once in place, they in turn shape how a person perceives and makes sense of subsequent experiences” (Fennell, 1997, p. 2)
– Low self-esteem may i) represent an aspect of a presenting issue ii)be a consequence of a presenting issue or iii) represent a longstanding vulnerability factor, preceding the onset of presenting issues
Activation of Bottom Line A first date
Predictions“I’m abnormal, I won’t be accepted if I am myself”
Anxiety
Maladaptive BehaviourUse of humour
Self critical thoughts“there’s something wrong with me, I’ll be alone forever
Depression
Confirmation of Bottom Line
Cognitive Model of Low Self Esteem (Fennell, 1997)
Proposed Treatment PlanAim Method
Socialising Alice to the CBT model Completion of hot cross buns and cross-sectional formulation
Challenging Alice’s self critical thoughts
Completion of thought diaries
Testing Alice’s assumption that she has to behave how she thinks others want her to in order to be accepted or loved
Exploring consequence of belief, advantages and disadvantages, identify alternative rule, behavioural experiments
Test Alice’s belief that she is abnormal
Continuum work
Engagement and Therapeutic Alliance
• Engaged Well– Socialised to CBT model – Contributes to session
• Alliance very good from the start– Open, honest, friendly
• However, too many jokes?– Eliciting emotion- avoidant?
Experience & Observe (Kolb 1984 and Lewin 1946)
SituationAware of client making many
jokes in therapy session
Cognitive“If I raise this it will be really awkward” “I’ll come across
as really formal”
PhysicalButterflies, heart rate
increased
MoodAnxious
BehaviourAvoided bringing this up in
conversation
Reflection
–Assumptions related to valuing humour in sessions –I didn’t fully consider the potential impact on the
emotional expression in the session–There is a need to validate my clients experiences, even if
she isn’t?
PlanUse of humour is advantageous to the therapeutic alliance
where appropriate, but can become a barrier to eliciting emotions
Summary
• Presenting issue of mild-moderate depression, with a previous episode of depression 3 years ago
• Assumptions/rules led to compensatory behaviours which became self-perpetuating
• Treatment plan aimed at increasing confidence through reducing compensatory behaviours and testing assumptions
Questions?