Case study on formulation of cognitive behavioural perspective

A formulation is a tentative explanation or hypothesis as to why an individual presents and maintains a particular disorder or circumstance at a particular point in the time (Weerasekera, 1993)

The present essay will look at the formulation of cognitive behavioural perspective in light of Cara’s case study. Becks cognitive model of psychopathology stresses the importance of thinking in the elicitation and maintenance of depression, anxiety and anger (Beck, 1970, 1976; Beck, Emery, & Greenber, 1985; Beck et el., 1979). Becks talks about the levels of cognitive assessment. One of the most pressing level are automatic thoughts that come spontaneously and is associated the problematic behaviour or disturbing emotions. In cognitive behavioural therapy (CBT) formulation is located within a scientific, experimental framework as a process in a role of the scientific practitioner (Tarrier & Calam, 2002). Kanfer and Saslow (1965) described the process of behaviour analysis as an alternative to psychiatric diagnoses (Tarrier & Calam (2002). The paper looked at and described in detail the individual problematic behaviour in relation to environmental stimuli rather than in terms of psychiatric diagnoses (Folette, Houts, & Hayes, 1992). Meichenbaum, 1977 and Wilson, 1978 work which derived from the work of Beck (Beck, Rush, Shaw, & Emery, 1979) lengthened the field of behavioural therapy.

Evidence suggests that there is much research evidence on CBT outcome research signifying its importance with different psychological problems (Roth & Fonagy, 1996), however there is not much research on CBT process outcome and very limited research on examining CBT case formulation (Bieling & Kuyken, 2003; Kuyken, 2005). However, Kuyken (2005) puts forward more relevant research.

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CBT is based on two assumptions, firstly a bio psychosocial context is implicated in the maintenance and development of a client’s emotional disorder sees (Beck, 1999). Secondly, although clients presenting problems arise in a bio psychosocial context, the clients’ perspectives are seen as the main focus in CBT (Johnston& Dallos 2010). Cognitive theory takes into account factors as to why a person may present emotional problems, and how the person perceives this through a process of making sense of their lives.

The essay will now look at the key ideas underpinning the process of CBT. Johnstone & Dallos (2010) suggest a framework for CBT formulation which refers to the levels and process of formulation in regards to the five Ps; presenting issues, precipitating factors, perpetuating factors and protective factors presenting issues which define the current problems in term of emotions thoughts and behaviours. Precipitating factors introduces the cognitive model and articulates internal and external factors that trigger the current issues the ABC model is also included in this factor. Ellis’s ABC model (Burns, 1989; Ellis, 1977; Trower et al. (1998) sums up the ABC model as follows, an Activating event A leads to emotional and behavioural consequences at C, with the emotional consequences being mediated by Beliefs B. Perpetuating factors articulates the internal and external factors that maintain the current problems. Predisposing factors is an in depth evaluation of what internal and external factors increased the persons vulnerability. Lastly, protective factors; what maintains the persons emotional health. This process will be used to outline the formulation.

Formulation

Presenting problems

Haynes and Williams (2003) an analysis of the presenting issues is essential to the development and understating of the problems. Cara’s presenting problems are described as paranoia, hearing voices delusional and unusual beliefs and aggressive behaviour. She experiences isolation and feels excluded from her friends, family and teachers. Cara’s delusional beliefs are that her teachers are in a racist conspiracy against her. Although there is much development on conceptualisations of problems such as hallucinations and delusional beliefs (Morrison 2001; Freeman & Garety 2004) at this moment in time there is not validated theory of psychotic symptoms to inform the practice of CBT. However Trower et al 2004 conducted a study which recognised the development of an effective cognitive therapy for command hallucinations by applying social rank theory. Although there is a lack of evidence to support disorder specific models of delusional beliefs, generic models will be used to when considering Cara’s problems. Kingdon and Turkington 1994; Morrison et al. 2004) emphasise the importance of knowing and understating the client presenting issues.

Precipitating factors

The next stage of the CBT formulation involves articulating the external and internal factors that that trigger the presenting problems (Johnstone & Dallos, 2010). Beck 1967, 1979 proposes that as a result of life experiences people develop dysfunction beliefs and assumptions about themselves, others and the world around them. These beliefs are triggered by incidences once this belief is activated this produces a negative automatic thinking. Precipating factors draw upon the ABC model Burns, 1989; Ellis, 1977; Trower et al. (1998) which refers to A- activating event, B – Beliefs and C- consequences. Here I’ll begin to formulate Cara’s case study in terms of the ABC model.

At the age of fourteen Cara meets a man of different race to herself and who is considerably older than she is. She receives negative comments from both strangers on the street and people that she knows. A few months later the boyfriend breaks up with her. Her belief is that no one understands the bond that they have for one another. As a consequence of this she feels rejected, betrayed and that she may not have been good enough for him. If Cara’s belief is to be loved and this is essential to her happiness depression could be triggered following rejection from her boyfriend. As depression develops rational thoughts are crowded out and depressive mood develops (Fennell, 2000).

Cara’s second activating event is the relationship that she has with the pupils in the new school that she attends, she has difficulty with connecting with her peers as she is one of the only black people in her school from a working class background. She feels that her friends and peers are laughing at her, making jokes at her expense and making rude gestures behind her back. Her belief is that her hair is falling and that her hair is too greasy. As a consequence of this she becomes withdrawn she feels isolated which lead to her paranoia. According to Tarrier (2009) individuals like Cara who suffer from psychosis have much difficulty in understanding the social world around them and tend to misinterpret other people around them, this leads to socially awkward behaviour

The third activating event drawn from Cara’s case study is the eye contacting that she has with her A- level teacher. Her belief from this event is that they share a special bond and that they are communicating with her and telling her that she is special (hallucination). As a consequence of this she attends class and starts to hear voices of one of the teachers. At the same time she becomes even more isolated from her peers. Romme and Escher (1989) conducted a study in which they found that 70 per cent of people who heard voices developed their hallucinations after a traumatic event. If we look at the case of Cara she was raped by her brother at the age of ten this event may have been the onset of her hallucination (it is important to note that from the case study her belief of her sexual trauma was not present to form an ABC). It is suggested that psychosis may emerge as a reaction as trauma for example (Ellason & Ross, 1997; Read, 1997) this comes from high rates of sexual abuse among psychotic populations, for example, (Goff et al., 1991) an the precipitating influence of negative life events on psychotic symptoms (Kingdon & Turkington, 1994; Romme & Escher. 1989). It should be taken into account that some of these studies have problems with their sample, and also that the life events literature is still unclear in relation to psychosis (Morrison et al, 2003)

Cara’s ABC model (Ellis, 1977) helps to build an understanding of Cara’s distress (Johnstone & Dallos, 2010).

Perpetuating factors

Although the ABC model is functional device, it has it restrictions in terms of helping to understand Cara’s emotional disorders. The model also does not explain what maintains her problem in the long term. Here I will draw on internal and external factors that maintains Cara’s problems and also draw on her cognitive, behavioural and physiological responses to her situation (Greenberger & Padesky, 1995). Greenberger & Padesky, (1995) approach is very similar to Lang, Melamed, and Hart’s (1970) three system model of fear maintenance and desensitisation. The CBT model hypothesises that a self perpetuating interaction between different domains maintains symptoms and distress (Deary et al, 2007)

Beck (1967, 1976) described the development and maintenance of depression from clinical observation. All the symptoms of depression derive from the negative thoughts that Cara has of herself and others around her. According to Blackburn et al (1996) negative cognitive beliefs are maintained by negative bias cognitive distortions; selective abstraction, arbitrary inferences, overgeneralisations, magnification of the negative minimisation of the positive and personalisation of negative outcomes. Referring back to Cara’s case study, her early negative experiences e.g. her father leaving her at a young age and her mother leaving her at her grandmothers’ house for long periods of time without any explanation could have maintained her psychosis into adult hood. Barlett 1932 and Piaget 1952 compromised a schema which recognises all of an individual’s past learning and knowledge. They are made up of beliefs and theories of one’s self and others. Therefore, this will effect what Cara encodes in her memory and her interpretations and her expectations. In depression the schemata are negatively toned, whether referring to self or others, because of early negative experiences with meaningful adults, they often reflect a theme of loss (Blackburn et al, 1996), in this case the loss of her father and the lack of closeness with her mother at a young age. This in turn led and maintained her dysfunctional depressive behaviour.

Cara’ social cultural conditions have also maintained her psychosis, according to Harrison et al. (2001) sociocultural conditions appear to modify long term course.

A combination of Beck Cognitive model (Beck 1976; Beck et al. 1979) and model specific health anxiety (Salkovskis and Warwick 1986) is helpful in understanding what maintain Cara’s problems. What maintain Cara’s psychosis are the responses that she receives from both her family and friends. For example Cara over hears her peers talking about how she is weird. This led to her isolation, which was her coping mechanism. According to Wells (1997) cognitive model of social phobia, an individual like Cara will engage in safety behaviours e.g. isolating herself from her peers. Such safety behaviour as isolation intensifies or prolongs unwanted symptoms (Wells, 1997).

The feature of posttraumatic stress (PTSD) disorder is reliving of an event from the past, with the same emotional intensity (Lee, 0000) there are three symptoms associated with PTSD: intrusions, avoidance and hyper arousal. It is one of the most common disorders in those who have suffered a traumatic event. (Litz & Roemer 1996) study indicated a lifetime prevalence of 5-10% in general population. The rate varies depending on the experienced event, the highest rate was observed in those who suffered rape (Lee & Young 2001). Several theories have suggested an account to this order, including information processing theory (e.g., Brewin et al. 1996) behavioural theories (e.g., Keane et al. 1985) and both socio biological theories and socio cognitive theories (e.g., Christopher 2004; Horowitz, 1986) and most recently (Ehlers & Clark, 2000). The latter theories are helpful in understanding the maintenance of PTSD (Tarrier, 2009). When Cara was raped by her brother she was threatened with violence to not say any thing to anyone. It is assumed that in this situation she was in fear and felt helpless. Ehlers and Clarks propose a cognitive model of persistence. They suggest that PTSD becomes persistent when individuals like Cara process the trauma in a way that leads to a serious threat. The threat arises as a consequence of negative appraisals of the trauma and/or a disturbance of the past memory characterised by poor elaboration and contextualisation, strong associative memory and strong perceptual priming (Ehlers & Clark, 2000). For example, Cara has avoided this issue, so when her boyfriend ends the relationship with her this may bring up the same emotions she felt during her rape, confusion, fear and helplessness and the whole experience is relived therefore maintained.

Another event drawn from study that keeps the problem going is another safety seeking behaviour (Salkovskis et al. 1996). She starts to hear voices of one of her teachers telling her that she is ok and that everything will be fine. When she receives her grades she is disappointed at the low grades. Her belief is now that the teachers are not on her side and that the teachers are in a conspiracy against her, this maintains her maladaptive beliefs.

Individuals suffering from psychosis tend to have a poor perception of themselves and low self-esteem. This concept can be hypothesised to manifest in negative self-schemas. The later factors explained impact upon and maintain negative self-schema. The consequence of Cara suffering this illness is the formulation of such negative self-schema, which then serves to bias the way information is assimilated hence these schemas are maintained and strengthened rather than being challenged.

Predisposing factors

Although the maintenance models help to understand what may be perpetuating a problem, there may still be some unclarity as to what led to the onset of the problem. So a thorough analysis of Cara’s life events and her reactions to these life events and what made it upsetting for her is beneficial in this factor. Brabban and Turkington (2002) proposed a stress vulnerability model and suggested that vulnerability will result in the development of problems only when environmental stressors are present. The particular stressors for Cara appeared to consist of several difficult life events, perhaps precipitated by neglect from both her mother and father and by the rape of her brother. Cara’s social position may have also led to the onset of her problems (Cromby & Harper, 2009) e.g. moving from a culturally diverse area to being one of the only black people in her school. As explained earlier trauma experiences are increasingly being recognised as important in the onset and maintenance of psychosis (Morrison et al. 2003) for Cara, the trauma seem to have led to maladaptive coping by avoiding the situation. These experiences combined with the break up of her boyfriend, moving to a foreign area and the loss of friendship, left Cara isolated with led to her paranoia. A number of key events have happened to Cara such as the rape can manifest itself as PTSD. Psychosis is the way that Cara may react to her life history (Boevink, 2006)

Protective Factors

Cara’s main strength is the drive she has for achieving well in school. She has ambitions to go to university. It’s not only important to know what is wrong with an individual but also look at what’s right. This would benefit Cara in terms of treatment (Moorey, 1996)

Integration

Although the essay has concentrated on CBT, Social inequalities and systemic perspectives may also be relevant to the client. If we look at the case of Cara and her formative childhood upbringing there seems to be a direct correlation between her latter behavioural issues and key points within her childhood. It is suggested that symptoms such as Cara are seen as problems in communication and interactions within the family. For instance, Cara was left with her grandmother for long periods of time without explanation, this childhood experience and attachment issue led to difficulties in forming and maintaining good relationships with her peers later on in life (Hobson et al. 2005). Criticism form Cara’s family when dating her white boyfriend could have also been the cause of her psychosis Brown, Birley and Wing 1972; Vaughn and Leff, 1976 support that family life can influence psychosis. The later suggests that the systemic perspective is relevant to Cara, the perspective sees the family as a system and individual distress as an expression of problems within the system.

Not only does trauma and family relationships create problematic life circumstances. Social and economic factors in Cara’ life also may have shaped her life experiences. For example moving from a council estate to a wealthy middle class area, this environmental factor could have been associated with mental health (Halpern, 1995) to conclude both systemic and social inequality perspectives could have been the trigger and maintenance of Cara’ problems.

Conclusion

Literature suggests that there are controversies and debates over the reliability and validity of formulation (Kuyken, 2003) although there is evidence for the reliability of cognitive case formulation (Bieling & Kuyken, 2003), and the effectiveness of cognitive therapy has received support from the evidence, the same cannot be said for the heart of the approach (Johnstone & Dallos, 2010). For instance, there is limited research related to an individual presenting problem nor is there a link between case formulation and improved outcome. Kuyken (2005) has suggested however research into case formulation. If formulation does not have a significant effect on the outcome this could indicate whether formulation is beneficial to an individual, for example, Chadwick et al. (2003) study of results showed that that there is no significant difference between case formulation on symptoms of anxiety and depression. In order for CBT formulation to be effective I suggest that social and political factors need to be taken into account so that the formulation is useful. The reliability and validity needs to be researched further for formulation to be more effective.