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5 P’s Model
The CBT formulation consists of 5 key stages which is known as the 5 P’s model. The 5 P which I will be mentioning are: presenting issues, precipitating, perpetuating, predisposing and protective factors. Within the ‘Presenting issues stage’ its about looking at the current problems or issues the person is facing, to get a clear understanding of what they are and then set goals or targets based around this. The next step ‘Precipitating’ is used to look at both internal and external factors and discover where they are linked, from this you get a greater picture of the overall problem. We then move onto ‘Perpetuating’ which looks at what factors are contributing to the remain of the problems the person is facing. ‘Predisposing’ looks at a wider understanding of the issues, looking at it in more lengthily way. The last P looked at is ‘Protective’ which as the name suggest looks at ways to prepare the client so that relapse is unlikely, this is done by looking at the strengths of the client as a platform to build on. I will go into further detail of the ‘5 Ps Model’ below. (Johnstone & Dallos 2009)
As I stated above this factor looks to get a wider understanding of what the issues is. It looks at situations both past and present which can be both experiences and distresses that lead to symptoms of a psychotic nature can lead to resolving the psychosis. This is an essential step.
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This inspires the development of a longitudinal understanding of a person’s problems. This is intended to inspire the identification of more in-depth interventions that aim to sustain change and prevent relapse (i.e., promote long-term behavioural adjustment).
It has been said that the experiences, incidents and or events in our life has an affect on both how we feel and behave. This can be both positive or negative but they have a direct correlation to how the person is today. What we understand today is shaped by what we believe and what we have experienced in our life.
This stage of “formulation involves articulating the external and internal factors that can activate presenting problems” (Johnstone & Dallos, 2010). Becks States that life experiences play a part in people dysfunctional beliefs and assumptions about themselves, others and the world around them (Beck 1967, 1979). These beliefs are set off by occurrences in the client life, and once this belief is activated it can lead to automatic negative thinking. Precepting 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.
The internal and external factors that maintain the current problems. To help treat the client with psychosis maintaining specific behaviour can be beneficial and help avoid frustration and upsetting experiences (Johnstone 2009). People with paranoia tend to avoid these situations which would lead to distress (Clark et al 2005). It has been documented that 90% of the population at some point have intrusive thoughts, or feel paranoid and feel people are doing things on purpose towards them. (Rachman & de Silva 1978, Salkovskis & Harrison 1984, sited in Tarrier et al. 2008).
Bentall (2004) had stated that obsessed person is highly sensitive to any threats to their self-esteem, therefore it is important to the individual to sustain the behaviour that they believe is protecting them from hurt to their self-esteem.
The person’s resilience and strengths that help maintain emotional health. The therapist provides a route easiest for the client by identifying methods that build on the client’s current resilience and strengths. According to Read et. all (2004) it is essential to reduce stress and traumatic events for people recovering from Paranoid Schizophrenia, and start to contribute in social activities. However, an important skill that they should try to perform is to assess a situation before jumping to conclusions.
One of the strengths of this formulation is that it is not fixed. It can be changed and reviewed as the treatment is in progress if any new information come to light. It is open to modification any time during the treatment period and any new evidence that crop up at any time will be discussed with the client. This is to ensure that the client understand any reason for change from what was originally agreed. Additionally, as it is a continuous process it allows the therapist to revise any incorrect hypothesis about any underlying mechanism at any stage. (Persons, 1998).
One of the weakness of this formulation is identifying that the client’s strength is not included the initial assessment and data collection. Another weakness is that sometimes the client might not want to disclose some information in their past which might assist the therapist in making the client understand that sometimes important part of their history in fluence the way they view the world.
Equally if there is lack of collaboration, this can be as a result of expectations from either client or the therapist for example if the client have expectations from the therapist because he sees him as the expert and should be able to provide all the answers to his problems without him the client having an input.
Based on what I have reviewed in this essay. I can state that formulations of everyone must be taken with care, since they are hypothesis and not statements of facts as pointed out by Butler (G Butler 2009). It would be difficult to say which formulation is correct, and if there is such a thing as a correct one, since everyone has an individual view of what is right or wrong. What must be looked at in every formulation is if the particular formulation seems to be the right one and benefit for the person with the psychosis. It is believed that CBT receives government support and funding because it is cheap and quick, even though the empirical evidence for it is weak (Hussain 2009). CBT has been found to not be effective in schizophrenia (Lynch et al. 2009). According to Dr Oliver James (Hussain 2009) CBT is over praised; what CBT achieves any other therapy can achieve to. As mentioned earlier different therapists have a different structure of formulations in CBT, this can be seen as a downside to the therapy, since it doesn’t have a particular structure that everyone follows. If present categories are used, formulation can be limiting and dangerous. (Goldman & Greenberg 1997)
- Dallos, R. and Vetere, A., 2018. Working systemically with families: Formulation, intervention and evaluation. Routledge.21-37). Routledge.
- Drayton, M., Birchwood, M. and Trower, P., 1998. Early attachment experience and recovery from psychosis. British Journal of Clinical Psychology, 37(3), pp.269-284.
- Goldman, R. and Greenberg, L.S., 1997. Case formulation in process-experiential therapy.
- Hawton, K.E., Salkovskis, P.M., Kirk, J.E. and Clark, D.M., 1989. Cognitive behaviour therapy for psychiatric problems: A practical guide. Oxford University Press.
- Johnstone, L. and Dallos, R., 2013. Introduction to formulation. In Formulation in psychology and psychotherapy (pp
- Persons, J.B., 1989. Cognitive therapy in practice: A case formulation approach. New York: WW Norton.
- Rachman, S. and de Silva, P., 1978. Abnormal and normal obsessions. Behaviour research and therapy, 16(4), pp.233-248.
- Tarrier, N., Wells, A. & Haddock, G. (1990). Treating complex cases: The cognitive behavioural
The main feature of Generalised Anxiety Disorder (GAD) is extreme and overwhelming fear as mention by (Wells, 2002). According to DSM-IV for a correct diagnosis of GAD to be obtained, the patient must have been over-worrying excessively every day for six months and over. The patient expects the worst to happen as they overthink events and situation that is normal for most of the population. (American Psychiatric Association, 1994). The main symptoms of GAD are restlessness, easily fatigued, difficulty concentrating, irritability, muscle tension, and sleep disturbance.
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Cognitive-behaviour therapy (CBT) is the integration of behavioural therapy, established in the 1950s to 1970s, and cognitive therapy established in the 1960s. Generally, it tries to deal directly with a client’s obvious symptoms through both cognitive and behaviour approaches. Cognitive theories target illogical views which are believed to be the underpinning of behavioural and emotional problems. CBT is well-established in the treatment of anxiety disorders. Within this essay I will outline and critically evaluate the theory and practical treatment of generalised anxiety disorder (GAD) using CBT method.
In understanding how CBT interventions are used in treating GAD, we must understand the model of worry that it is founded. Beck (1976) fashioned the most commonly used types of anxiety model, which connects feelings and thinking. In this model, it is the client’s thoughts and images connecting to an expected danger that instantly precede, and cause anxiety attacks. By evaluating their environment, anxious clients exaggerate both the prospect and severity of an adverse event occurring and so take self-protective action (Blackburn, 1995).
There are different types of interventions are used for treating GAD, and this includes both directive and non-directive therapies. According to research carried out by (Fisher & Durham 1999), they observed the usefulness of different interventions and that the number of clients achieving complete recovery. Their result showed that the most positive interventions in their meta-analysis were CBT, which achieved a recovery of 51% and applied relaxation, which achieved a 60% recovery.
Cognitive Restructuring or Challenging Negative Thoughts is one of the CBT intervention used to treat GAD. They generally concentrate on two main aspects: cognitive work intended at challenging the client’s beliefs and thought processes as well as behavioural work intended in educating the client anxiety management strategies (Wells, 2002). According to Borkovec (2002), it defines the cognitive facet of CBT as concentrating on the way the client sees the world and trying to transfer this into a correct balance. Mostly, this is done by eliciting how the client sees situations worryingly. The client is then encouraged to apply rational thought processes to their observations and to challenge the way they are thinking. The therapist will try to displace these fundamental thought processes with cognitive clarifications that will not lead to increased anxiety. Clients are usually given a thought log and encourage to practice identifying and recording thoughts that they have during severe events and resulting consequence as homework. They are encouraged to focus mainly on thoughts that provoke anxiety for them. Once they become more proficient at recognizing their negative thoughts, then they will be able to start challenging them, and the consequence will then be that though they were nervous during the task but realize that the consequence was not as unfortunate as they expected. This will make it easier next time they encounter the same thought.
Relaxation Training. This treatment technique entails educating client who worries excessively, on how relaxation is an essential part of the healing process. (Borkovec, 2002). This treatment method entails schooling the client in different methods for relaxing the body such as meditation, progressive muscle relaxation, and relaxing imagery. Clients are encouraged to repeat these relaxation exercises even when they are not anxious, so they feel comfortable with their application. In some conditions, clients will be exposed to situations which make them anxious in order to provide genuine exercise chances.
Mindfulness Training. The mindfulness training is the art of focusing on the here and now and also to be aware of the moment and not focus so much on the future. The client is encouraged and offered training that will assist them to focus on the present rather than worry about future events which they have no control over. (Borkovec, 2000).
Systematic Exposure. This is a process that encourages the client to face their fears and test their theories / worst-case scenarios. By doing so, it should allow the person to make peace and stop triggering anxiety. This could be done through experiments. For instance, a client who is afraid of heights could be encouraged to start conquering their fear of this by going into a tall building and looking out through the closed window and while this is going on their level of anxiety should be monitored to ensure that they are not overexposed. This should be increased gradually throughout the therapy sessions and at each time, increase the level of the exposure until they reach a stage where they are comfortable going out into the balcony and looking down below with minimal anxiety. (Wilkson et al. 2011)
Stimulus control. This is about informing the client to allocate a period each day dedicated to worrying. During this time, they would put into practice their cognitive skills. Two other methods that could be used are behavioural activation strategies, and this is to motivate the client to participate in more favourable activities and imagery rehearsal methods which involve practicing new responses to external signals likely to cause worry (Borkovec, 2000).
Researches have shown that Cognitive-behavioural therapy can be as effective as medication in treating some mental health problems, but it may not be adequate or suitable for everyone.
It is beneficial in cases where drugs alone have not been successful. Also, it can be accomplished in a reasonably short period compared with other talking therapies. It shows useful and practical tactics that can be used in everyday life, even after the treatment has finished. Research shows that 80% of patients treated recover adequately and can lead to a healthy life.
CTB has no side effect, unlike medication for the treatment, and as such, it can be used over a long-term period.
Adversely for CBT to be effective, the client should be willing to commit to the treatment plan in order to benefit from the session. If the client is unwilling to commit, then it will be difficult for the therapist to help, so co-operation from the client is highly essential.
The client often finds attending regular CBT sessions and carrying out any extra work between sessions time-consuming. Hence some client never completes their sessions .it is suitable for people with more complex mental health needs, as it requires controlled sessions. It involves client challenging their emotions and anxieties, and they may experience initial periods where they are anxious or emotionally uncomfortable, thereby not fully willing or are not prepared to deal with it.
As it focuses on the client’s present issues and the ability to change themselves, i.e., their thoughts, feelings, and behaviours, but does not address any more extensive glitches in systems or families dynamics as this usually have a substantial impact on people’s health and wellbeing. Critics argue that because CBT only addresses current problems and focuses on specific issues. It does not address the possible underlying causes of mental health conditions, such as an unhappy childhood. It is not suitable for treating mental disorders in the long term. It should be used in conjunction with other types of therapy, like psychodynamic therapies for long term cure.
CBT does not investigate genetic factors, interpersonal factors like social life. Abnormal thoughts do not always cause anxiety disorders. Additionally, it does not consider the fact that sometimes a third party might be responsible for client mental disorder, for example, victims of bullying.
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