A psychological formulation of a case study based on the cognitive-...

Aaron T. Beck, the founder of Cognitive behavioural therapy (CBT) defined it as “an active, directive, time limited approach used to treat a variety of psychiatric disorders”, (Beck 1979). Beck, inspired by Albert Ellis, developed cognitive therapy in the 1960s after a realization he made while conducting free association with patients in the context of psychoanalysis when he noted that patients had not been reporting certain thoughts at the fringe of consciousness, thoughts which often preceded intense emotional reactions. This led Beck to begin viewing emotional reactions as resulting from cognitions, rather than understanding emotion within the abstract psychoanalytic framework, (Beck 1999). Cognitive therapy rapidly became a favorite intervention technique to study in psychotherapy research in academic settings. CBT includes a number of therapeutic procedures, such as cognitive therapy, rational-emotive psychotherapy, problem-solving interventions, and exposure. In a restrictive definition, it indicates psychotherapeutic approaches that seek to produce change in cognition as a means of influencing other phenomena of interest, such as affect or behaviour. A broader definition stems from the growing awareness that most psychotherapeutic approaches combine cognitive and behavioural elements. The past two decades have witnessed an increasing awareness of the common ingredients that pertain to the psychotherapeutic process and that cognitive behavioural approaches share (Fava, 1998). There is empirical evidence that CBT is effective for the treatment of a variety of problems, including mood, anxiety, personality, eating, substance abuse, and psychotic disorders. Treatment is often manualized, with specific technique-driven brief, direct, and time-limited treatments for specific psychological disorders. CBT is used in individual therapy as well as group settings, and the techniques are often adapted for self-help applications (Foa et al, 2003). The practice of CBT emphasises events in the “here and now”, rather than extensive exploration of the client’s background and particularly their childhood.

According to the cognitive model, negative symptoms function partly as a maladaptive strategy aimed to protect individuals from expected pain and rejection associated with engagement in constructive activity. CBT includes interventions from recovery and empowerment movements designed to address self-stigmatized views. Cognitive behavioral therapy for negative symptoms depends on careful assessment of neurocognitive functioning, symptomotology, daily functioning and quality of life, beliefs, behaviors, and images. Assessment is an ongoing process achieved through several methods, including formal measures, functional assessment of the client’s behavior, and self-monitoring of thoughts, images, behaviors, and emotions (Canther, 2009).

One goal of CBT is to solve overt problems by changing cognitions and behaviours. Change in underlying cognitions, or schemas, is also considered quite important, both in the process of treating overt problems and to prevent relapse . Therefore, reliable methods for assessing patients’ overt problems and underlying schemas are needed. (Liese, 1995). The following formulation is based on a case study of a girl called “Cara” and has been constructed based on a CBT approach. This formulation is based on the five P’s of the process of CBT formulation as outlined by Johnston & Dallas (2006); presenting issues, precipitating factors, perpetuating factors, predisposing factors, and protective factors.

Presenting issues

Cara presents a number of problems which include persistent delusional beliefs with both persecutory and grandiose themes, hearing voices, and low self esteem. Some of her symptoms could indicate that she suffers from paranoid schizophrenia, however not enough information is available to make this assumption. She finds it difficult to relate to both her peers, and other people at work, has increasingly isolated herself and is struggling with her school work. She left her job due to feeling persecuted, and thinks that there is a racially discriminating conspiracy against her.

Precipitating factors

Despite no specific intervention being used to address past trauma in CBT, patients often link their automatic thoughts to past traumatic experiences or fear responses and discussion of this help them to understand the triggers for their delusional thinking (Brakoulias, 2008). Stressful events that triggered Cara’s current psychological problems include her boyfriend leaving her, her mother starting a new relationship, a move to Southampton, and attending a new school. These four precipitating factors have been summarised according to the ABC Model to facilitate the process of understanding the underlying thoughts that have led to Cara’s false beliefs, and assumptions have been made about likely beliefs that she holds.

Activating event: Cara’s white boyfriend leaves her

Beliefs: I am not good enough/I am not good enough for him because I’m black

Consequence: Cara isolates herself/Develops paranoid delusions about a conspiracy in which everyone is racially discriminating against her

Activating event: Cara’s mother starts a new relationship

Beliefs: I am alone/I am abandoned

Consequence: Cara isolates herself

Activating event: Cara moves to Southampton

Beliefs: I am alone/I am abandoned/I am unwanted.

Consequences: Cara isolates herself and finds it hard to make friends

Activating event : Cara starts attending a new middle-class school with a minority black population

Beliefs: I am not good enough/People are racially discriminating against me/People notice me because I’m different.

Consequence: Cara isolates herself and develops paranoid delusions about a conspiracy in which everyone is racially discriminating against her

Perpetuating factors

Paranoia is considered a threat belief in which the person perceives that others have intentions to harm them now or in the future with little or no supporting evidence. These beliefs appear to be accompanied by considerable anxiety, worry, and behavioural avoidance (Freeman & Garety, 2003). Recent models of persecutory delusions have emphasised a multitude of factors that lead to the formation and maintenance of paranoid beliefs. Paranoia appears to be largely influenced by emotional, cognitive, and environmental factors (Freeman et al., 2002). Garety and colleagues used probability reasoning tasks to illustrate that delusional patients ”jump to conclusions”, i.e., these individuals require less information before they adopt a hypothesis (Garety, 1991). Strauss (1991) suggested that delusions may evolve from less extreme thoughts and over time begin to fade back into those themes again. In the same way Cara has constructed false schema’s over a long period of time. These schema’s reflect her subjective perceptions of a world in which she feels “threatened”, and not an objective perspective based on evidence. In terms of attributional style, persons with persecutory delusions tend to exhibit a ”personalising” bias in which they tend to blame others rather than situations for negative outcomes (Kinderman & Bentall, 1996, 1997). In the same way Cara blames teachers and pupils for her poor exam results, and her work colleagues for having to leave her job.

Schemas, or core beliefs that underpin and cause some of Cara’s overt problems when activated by life events or situations were examined as perpetuating factors. Two main factors that maintain false beliefs or schemas from a CBT viewpoint would be safety behaviours, and seeking evidence. Safety behaviours are those behaviours that makes a person feel safe, and in the case of Cara this means isolating herself. However, due to limited interaction with others, Cara is unable to collect evidence that contradict her schema’s, i.e. “Everyone is out to get me”. By collecting only evidence that support her schema’s, e.g. Cara overhears a friend calling her “weird” and this confirms a false belief; “I am different”, Cara is unable to challenge her very subjective belief system, or to consider evidence that contradict her beliefs. In this way false beliefs are maintained. (Please see Appendix for a list of other perpetuating factors).

Activating event: Cara isolates herself

Beliefs: Everyone is out to get me/I am alone/People notice me

Consequence: Cara does not interact with anyone so is unable to collect any evidence to the contrary/Cara has difficulty in making friends due to isolating herself/Cara draws attention to herself by not interacting with other people

Activating event: Cara overhears a friend calling her weird

Beliefs: To Cara this provides evidence for established schema’s; There is something wrong with me/There is a conspiracy against me

Consequence: Cara isolates herself even more/Cara’s false schema’s become more established

Activating event: Cara seeks out black and Asian girl as friends

Beliefs: People discriminate against me because I am black

Consequence: By not befriending white pupils, Cara is unable to test her hypothesis

Cara’s social isolation can be conceptualised as an avoidance response that serve to protect her from anxiety and social threat; it seems to be closely related to her paranoia and auditory hallucinations. The tendency to see hostility may be a type of data gathering bias in which there is a failure to fully attend to important aspects of situations (visual scanning; Combs et al., 2006), or a form of the jumping to conclusions bias in which decisions are made quickly (Broome et al., 2007).

Predisposing factors

Some predisposing factors have been summarised according to the stress-vulnerability model. (Please see the appendix for a quantitative description of these events. Unfortunately there is no record of how Cara responds to the situations physiologically).

Quality of events

The particular stressors for Cara consist of having had a series of difficult life events. Cara’s father left them when she was a small child and she was sent to live with relatives for long periods of time with no explanation. Her mother was not able to give Cara the attention that she needed, and Cara felt increasingly disconnected from her. Although the effects of these early events on Cara are not clear, she may have felt confused, abandoned, alone and unwanted, and this could have led to beliefs of not being good enough which were further re-enforced when Cara suffered sexual abuse at the hands of her brother, aged 10. Cara isolated herself, a defence mechanism which she also uses later in life to protect herself. Being sexually abused by a close relative could also have led to feelings of not being able to trust anyone. A failed sexual relationship at the vulnerable age of 14 would have further reinforced Cara’s low self esteem, feelings of distrust and of feeling abandoned and unloved. Cara felt that this was the only person who ever understood her, and this betrayal led to later beliefs that everyone is “against” her. Because the man was white the relationship attracted a lot of negative attention, and this in combination with the fact that he had a white girlfriend all along led to some of the delusional beliefs Cara developed about being racially discriminated against when moving to Southampton at the age of 16, and attending a school with a minority black population. The move to Southampton would have triggered earlier feelings of being alone and abandoned, and earlier feelings of disconnectedness with her mother who was absorbed in a new relationship at this time. It is at this point that Cara also started feeling self conscious about her personal appearance, especially her hair, and starts thinking that everyone is noticing her because she is “different”, being one of only a few black pupils. She becomes paranoid, and thinks that everyone is mocking her behind her back. Cara re-creates the feelings from her previous relationship of being “special” or different when she starts believing that a teacher is communicating with her non verbally, telling her that everything is going to be ok. This reflects on her need for acceptance as she feels increasingly disoriented and tries to make sense of her inner psychological turmoil. As Cara increasingly starts isolating herself, believing that everyone has a conspiracy against her, she is unable to collect evidence that contradict any of her false beliefs. Instead, she seeks evidence to confirm her already deep seated negative beliefs, and when her exam marks plummet she is convinced that everyone is against her. She starts hearing a second, negative, voice who mocks her.

Protective factors

Cara has a record of doing well academically and is ambitious. She isolates herself when in danger as a protective measure. Cara seeks approval, and will most likely co-operate in treatment.

Another psychological perspective that could have been used is the Social inequalities theory. According to this theory; “The unequal of economic and social resources in society is central to explaining why some groups are more likely than others to seek help from psychological services (Fryer, 1998). A social inequalities formulation recognises that people are not passive in the face of trauma, but engage instead in counter-power resistances (White, 2004). Considering Cara’s ethical and socio-economic background, this approach could also have been effective. Cara’s low self esteem, as well as her delusions relating to a racially discriminating conspiracy, and her false belief that “everyone is against me” could be looked at from this perspective. Had this formulation been used attention would have been given to the construction of meaning and narrative, and to significant events and reactions over time. In contrast to CBT, more time would be spent on significant events that caused distress to Cara, as well as issues surrounding class consciousness and the way in which certain oppressive practices have become internalised and acted on Cara’s identity formation (Johnstone & Dallos, 2006). However, due to Cara’s safety behaviours (i.e. isolating herself) one could argue that gathering evidence that contradict her false belief systems would be more fruitful. Overly identifying with other people from the same ethnical and socio-economical backgrounds could lead to Cara collecting evidence that support her false schema’s.

In conclusion; during her CBT treatment Cara’s core beliefs and false schema’s will be challenged. The common formulation of CBT is to see delusions as maladaptive beliefs developed from non-psychotic antecedent factors. Therapy comprises assessing the impact of the delusions on the patient’s everyday behavior and collaboratively helping the patient modify the beliefs both by directly testing them and by modifying associated premorbid beliefs (e.g., ”I am a worthless”) that may be driving the psychotic symptoms (Beck et al, 2009). It is well known that delusional beliefs can be ameliorated by cognitive behavioural therapy (CBT). It has been shown to effectively reduce delusional conviction in approximately 50% of treated cases (Jakes et al., 1999). Another study by Wiersma et al. (2000) found that cognitive behaviour therapy in patients suffering from ‘hearing voices’ demonstrated durable effects on the target symptoms of hallucinations and their burden, and also on functioning in daily activities and social relationships. This result of durable improvement of cognitive behavioural therapy supports other findings from the literature (i.e. Sensky et al., 2000; Tarrier et al., 1999).

However, a study on CBT by Brakoulias, et. al, 2008, found that although CBT is effective in reducing delusional conviction, there was no accompanying change in reasoning style. This would imply that delusional conviction was reduced in patients by a process that does not involve modification of general reasoning styles. Thus, CBT may act to improve reasoning in a limited manner, pertaining only to the usual scenarios mentioned in sessions, whilst general cognitive biases and impairments will remain. (Brakoulias, 2008). The goal of CBT for negative symptoms is not necessarily to restore clients to their premorbid level of functioning, but rather to help them break out of this shell by mobilizing their personal and situational resources and fostering emotionally meaningful reengagement with the world around them (Canther, 2009).