contextualise cbt skills within case conceptualisation, formulation

7/30/2019 Contextualise CBT Skills Within Case Conceptualisation, Formulation

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case conceptualisation,

formulation and session

managementDr George Varvatsoulias
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Basics prior to case

conceptualisation
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Case-conceptualisation or case-

formulation? Conceptualisation: Making sense of the

condition together with the client Formulation: Working collaboratively on

agreed SMART goals and Interventions Case-conceptualisation: Rationale for

the condition, personalisedunderstanding of the condition to theclients needs

Case-formulation: Setting goals in theshort-term so these to be advanced inthe long-term via appropriatemethodology/CBT interventions


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Skills in use from case-

conceptualisation Explanation of the conceptualisation

rationale to the client

Description of current problem(s)

History of the problem(s): Early

experiences/critical incidents

Key maintaining processes and

hypotheses keeping the problem(s)going

Helping the client understand

cognitive and functional ABC models


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Individualised picture of skills

(1) Problem description in the here and

now

a. Cognitions

b. Emotions Affects

c. Behaviour(s)

d. Physiological changes or bodily

symptoms

Problem description in the past

a. Predisposing factors (Why me?)

b. Preci itatin factors Wh now?


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(2) Triggers and modifying factors

a. Triggers: What factors make the

problem more or less likely to occur

b. Modifiers: What contextual factorsmake the difference to how severe

the problem is when it does occur

c. Intensifiers: Size, speed, proximity,sound(s)


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(3) Many factors can operate as triggers or

modifiers

a. Situational variables (situations, objects,

places)b. Social/interpersonal variables (self and

others)

c. Cognitive variables [topics of thought

related to trigger(s)]

d. Behavioural variables (occurrence during

the presence of activities with or without

others)


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(4)e. Physiological variables (changes in the body and

their effect to the problem)

f.Affective variables (do existing mental conditions

worsen the problem? Locus of control)

Consequences

a. What is the impact of the problem in ones life?

b. How salient others respond to ones problem?

c. Coping strategies that have tried and their effect

on ones problem

d. Is the person under the influence of substances

to cope with the problem?


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Maintaining processes (1)

Safety behaviours


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Escape/Avoidance


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Reduction of activity


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Maintaining processes (4) Catastrophic misinterpretation


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Self-fulfilling prophecies


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Scanning or hyper-vigilance


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Performance anxiety


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Fear of fear

Anxiety

(Originally arisingfrom any cause)

Aversive anxietysymptoms

(Anxiety symptomsexperienced as

extremely threatening,unpleasant, intolerable)

Anticipatoryfear of

becominganxious


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Perfectionism

Negative personalbeliefs

I am worthless,useless, I am not

competent or capable

High standards for self

I can conceal myuselessness, if I doeverything perfectly,always succeed, etc.

Impossible to achievestandards

Always see self asfailing


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Short-term reward


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9-box formulation for a

depressed client


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An example of case formulation

in written form (a) Early experiences

You told me you come from a family with

strict religious values; that your father was a

dominant figure and that he was easily

becoming angry at you.

Critical incidents

In your childhood whilst living with family -

you werent allowed to say your opinionfreely. During your school and university

years when teachers were asking questions

you did not answer them and though you

were trying grades from assignments were


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in written form (b) Event what happened

You were referred to me by your parish priest

because of depressive elements in your

behaviour. The reason you came to see me was

that you were asked to make a presentation atschool where you are working as a teacher

and you didnt.

Thoughts that came to your mind after that event

Your thoughts at the time were I will fail 08/10,

I will be humiliated 07/10. You have also

imagined that colleagues will ask you questions

you wont be able to answer 07/10 and that they

will laugh at you 08/10.


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in written form (c) Physical and emotional sensations

What you have physically felt were mouth

numbness and heart pounding. Emotionally

you have felt distressed 08/10, in low

mood 09/10, sad 09/10, helpless 08/10

and lonely 08/10.

What you did-behaviours

What you said to your colleagues was youhad to write students reports. In saying so

you left the room and you went to write

these reports. After you did what you said

you felt relieved 09/10 that you didnt do the


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in written form (d) Core beliefs

In exploring a bit further what you thought about yourself you told me

you believe you are nothing 09/10, that you are worthless 09/10,

that you dont mean anything 8/10, that others wont notice you

because they will consider you as being useless 09/10.

Rule for livingTo compensate for such beliefs you expressed the rule If I dont

show others how capable I am I feel unimportant 08/10.

During every session you completed the Patients Health

Questionnaire with scores between 15 and 18 out of 27 (moderately

severe depression), the Becks questionnaire for depression with

scores between 25 and 26 out of 63 (moderate depression) and the

Hopelessness Depression Symptom Questionnaire with scores

between 38 and 42 out of 96 (moderately severe depression). In all

three questionnaires you were identified suffering from moderately

severe depression, which is a clinical component of unipolar major

depression.


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in written form (e) Interventions-Cognitions domain

Cognitive restructuring: modifying irrational thoughts via

debating.

SMART discussed and agreed: Better knowledge

acquisition on the subject-matter Irene teaches at school

Feelings domain

Developing coping strategies to reduce negative emotional

responses.

SMART Goal discussed and agreed: Walking in the park

Behavioural domain

Weekly activity scheduling: keeping activities well-planned

and scheduled on a weekly basis.

SMART Goal discussed and agreed: Activity planner

presentation before colleagues every week


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Possible problems during

assessment (1) Problems for the practitioner

1. Difficulty in gathering information to

be used for formulation

2. Replacing wrongwith correctquestions, such as open and not

closedones, as to eliciting and

elaborating information provided byclients

3. To be careful ofpersistentand

irrelevantareas of questions


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Possible problems during

assessment (2) Problems for the client

1. The client has become so used to the

problem that he/she no longer notices

the factors in viewed to be assessed2. Avoidance or safety behaviours, one

of most common is the client to jump

from one topic to another3. Difficulty in reporting thoughts and

emotions. The expression I feel...

many times refer to thoughts and not

emotions


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Possible problems in making

formulations Effect is not purpose (Behaviours and

consequences do not necessarily refer to

intentions)

Censoring the formulation (Formulation is a

collaborative process and every information

provided from the client is respectfully

recorded)

Spaghetti junction (Teaming out informationwith other information when they are relevant

or similar)

Tunnel vision (Idiosyncratic formulation in

terms of supporting and refuting hypotheses


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Formulations need to make

sense The hot cross bun perspective

Behaviours

Physiology

Emotions

Thoughts


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Core beliefs and schemata

should be:1. Targeted because they are

fundamental parts found deeper than

NATs (Negative Automatic Thoughts)

or behaviour(s)2. Modified so that to be altered

3. Controlled in terms of their

connection with others and the world(environment)


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The process of assessment


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Session management (1)

Assessment phase:a. Gather information

b. Analyse information using CBT theory

c. Develop/modify hypotheses about important

processes

d. Initial tentative ideas about formulation

e. Possible need to modify formulation

f. Discuss with client and modify as necessaryg. Agreed Formulation

h. Treatment plans

i. Note further information acquired during

treatment


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