Hot Cross Bun Formulation

The purpose of this study is to reflect on the package of care offered to a client and to critically evaluate the evidence base for the model which might be considered ‘best practice’ for a specific client problem, or issue. This entails identifying a particular client’s presenting issues while describing the evidence that is available for a suitable therapeutic approach, or model which would promote best practice. The study will reflect on a client who has been diagnosed with post- traumatic stress disorder (PTSD) as a result of a road traffic accident (RTI) and concentrates on the use of imaginal exposure therapy (IET) for the treatment of symptoms. Triggers and maintenance factors contributing to the clients deteriorating well-being will be explained using formulation as well as the protective and predisposing elements that were explored in therapy. Relevant literature will be cited throughout and appropriate research articles that have been critically reviewed will be discussed. Presentation, referencing and informed consent are consistent with the School of Health and Social Care’s guidance and have been adhered to throughout this assignment.

Introduction

PTSD is an anxiety disorder that can develop after exposure to one or more terrifying events, in which grave physical harm occurred or was threatened. It is a severe and ongoing emotional reaction to an extreme psychological trauma. The trauma may involve someone’s actual death or a threat to the individual’s or someone else’s life. The PTSD sufferer is affected to a degree that usual psychological defenses are incapable of coping.

Reports of battle-associated stress appear as early as the 6th century BC. PTSD-like symptoms have been recognised in many combat veterans in many conflicts since. These symptoms have been called shell shock, traumatic war neurosis, and Post-Traumatic Stress Syndrome (PTSS). The modern understanding of PTSD dates from the 1970s, largely as a result of the problems that were still being experienced by Vietnam veterans.

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The term Post Traumatic Stress Disorder was coined in the mid-1970s. Early in 1978, the term was used in a working group finding presented to the Committee of Reactive Disorders of the American Psychiatric Association. The term was formally recognised in 1980 in the third edition of the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association.

Although a controversial diagnosis when first introduced, PTSD has filled an important gap in psychiatric theory and practice. From an historical perspective, the significant change ushered in by the PTSD concept was the stipulation that the etiological agent was outside the individual him or herself (i.e., the traumatic event) rather than an inherent individual weakness (i.e., a traumatic neurosis). The key to understanding the scientific basis and clinical expression of PTSD is the concept of “trauma.”

DSM-IV-TR criteria for PTSD

In 2000, the American Psychiatric Association revised the PTSD diagnostic criteria in the fourth edition of its Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR)(1). Diagnostic criteria for PTSD include a history of exposure to a traumatic event meeting two criteria and symptoms from each of three symptom clusters: intrusive recollections, avoidant/numbing symptoms, and hyper-arousal symptoms. A fifth criterion concerns duration of symptoms and a sixth assesses functioning.

PTSD is unique among other psychiatric diagnoses because of the great importance placed upon the etiological agent, the traumatic stressor. In fact, one cannot make a PTSD diagnosis unless the patient has actually met the “stressor criterion” which means that he or she has been exposed to an historical event that is considered traumatic. Clinical experience with the PTSD diagnosis has shown, however, that there are individual differences regarding the capacity to cope with catastrophic stress so that while some people exposed to traumatic events do not develop PTSD, others go on to develop the full-blown syndrome. Such observations have prompted a recognition that trauma, like pain, is not an external phenomenon that can be completely objectified. Like pain, the traumatic experience is filtered through cognitive and emotional processes before it can be appraised as an extreme threat. Because of individual differences in this appraisal process, different people appear to have different trauma thresholds, some more protected and some more vulnerable to developing clinical symptoms after exposure to extremely stressful situations. Although there is a renewed interest in subjective aspects of traumatic exposure, it must be emphasised that exposure to events such as rape, torture, genocide, and severe war zone stress, are experienced as traumatic events by nearly everyone.

The National Institute for Clinical Excellence (NICE) has published guidance to help the National Health Service (NHS) recognise and treat people who develop PTSD after traumatic events. Recommendations include psychological treatment in the form of trauma-focussed cognitive behavioural therapy (CBT) and/or a course of anti-depressant medication while receiving therapy.

Trauma-focussed CBT focuses on a person’s distressing feelings, thoughts (or ‘cognitions’) and behaviour and helps to bring about a positive change. In trauma-focused CBT, the treatment concentrates specifically on the memories, thoughts and feelings that a person has about the traumatic event.

Imaginal exposure therapy (IET) is a component of trauma-focused CBT and involves revisiting the traumatic memory or memories in a safe and controlled environment so that the intensity of the individuals’ anxious and fearful reactions (thoughts, emotions, physical sensations and behaviours) is reduced.

Clients are exposed to the trauma memory by repeatedly describing the events of the trauma aloud until the anxiety response is reduced. This process is referred to as habituation. The treatment aims to eventually eliminate the fearful responses so that the client can face a feared situation without experiencing anxiety or fear. The goal IET is to process the trauma memories and to reduce distress and avoidant behaviours that the traumatic memory evokes.

CBT, as we know it today, is a result of a group of modern related therapies that have empirical psychological support. There have been two main influences to modern CBT and these are behaviour therapy (BT), as developed by Wolpe, Skinner and others in the 1950’s and 1960’s and cognitive therapy (CT) as developed by Beck and others in the 1960’s and 1970’s (Westbrook, et al. 2011, p2).

Freudian psychoanalysis had dominated the psycho-therapeutic world since the late 1800’s, but in the 1950’s, Eysneck and others in the psychological community questioned the lack of empirical evidence to support psychoanalysis. As a result, BT developed within the academic and scientific psychology community, basing its methodology on observable events between stimuli and response. Despite the success of BT, there was still some dissatisfaction with what was seen as the limitations of a purely behavioural approach (Westbrook, et al. 2011, p3). Beck and others were developing ideas about CT as early as the 1950’s; these ideas focussed on mental processes such as thoughts, beliefs and our interpretation of events, and continued to maintain an empirical approach to validate its theory to the psychological world (Westbrook, et al. 2011, p3). Although Beck was not the first to link faulty behaviour with irrational thought and unhealthy emotions, his work revolutionised the psychology world and continues to be used today.

Background to the Client

Throughout this assignment the client will be referred to as T. Protecting the client’s identity complies with the British Association for Counselling and Psychotherapy (BACP) and the British Association of Cognitive and Behavioural Psychotherapies (BABCP) guidelines regarding client anonymity as described in the Ethical Framework for Good Practice and fulfils the requirements of the University’s School of Health and Social Care’s policy on confidentiality.

T was seen in a primary care setting with a counselling service that offers short to medium term therapy for clients over the age of 16 years. She was referred to the service by her GP. She is a 25 year old female who is married with two boys aged 7 and 5 years. She is currently unemployed and lives in social housing with her husband who works in a local factory. T was raised and lived in an area where the 2007 Index of Deprivation (ID2007) indicates deprivation is 110.6% higher than the national average. There is a higher proportion of the working age population claiming incapacity benefit than the County average (Area Action Partnership). T first went to her GP shortly after being released from hospital after an RTA. She was a front seat passenger and received injuries to her face, arms and legs which included severe bruising, cuts and a temporal mandibular joint (TMJ) injury. Three months after the accident T continued to experience nightmares and flashbacks. The GP’s letter to the service noted the client’s deterioration and the original diagnosis of acute stress disorder (ASD) that had been diagnosed in the first month following the accident was amended to PTSD. Several studies have provided convincing evidence that early CBT treatment of ASD reduces the possibility of the development of PTSD (Moulds, et al. 2009, p16). ASD was introduced into the fourth edition of the diagnostic statistical manual (DSM) in 1994. The diagnostic criteria for ASD (Appendix A) are similar to those of PTSD, but differ in two fundamental areas. Firstly, ASD can only be diagnosed in the first month following the traumatic event and secondly, ASD includes a greater emphasis on dissociative symptoms (American Psychiatric Association, 1994).

During their consultation, the GP noted that T had become withdrawn and distanced from her family and friends, she reported feeling like she was “watching the world from inside a bell jar”, this dissociative symptom is described as derealisation, and is common in ASD patients (Simeon and Abugel, 2006, p86). The GP assessed T using the Patient Health Questionnaire (PHQ – 9) and the General Anxiety Disorder Assessment (GAD 7) which resulted in scores of 15 and 19 respectively. These scores indicate that T was suffering with moderate to severe anxiety with depression.

T was seen over a period of 13 sessions. The duration of each session lasted between 1 hour and 90 minutes. Longer sessions were included to provide sufficient time for sharing the trauma history and allow time for anxiety levels to decrease (Leahy and Holland, 2000, p197).

The contract between the counselling service and T was explained. This included informed consent to tape sessions, confidentiality and its limitations and an evaluation of risk. Evaluation of risk is an important part of the therapeutic process and is done throughout therapy. It involves assessing the client, the environment and also the therapists own personal and professional limitations (Mueller, et al. 2010, p 65). CORE OM was used to calculate a risk score and also to assess T’s suitability for therapy. The Cognitive Therapy Rating Scale as developed by Safran and Segal was not available to the therapist during the first session, but subsequent reviewing of the scale indicated that T was a suitable candidate for cognitive behavioural interventions. CORE OM score is shown below in figure 1.

Prior to developing a treatment plan, the therapist socialised the client to CBT explaining the evidence that supported using CBT interventions for PTSD. (Bryant, et al. 1999) and (Westbrook, et al. 2011, p81-83). First session therapist notes detailed T’s past history, the development of problems and the protective factors in her life (Appendix B). T was clear about what she wanted from therapy. Her problems fell into three main areas: (1) Nightmares, poor sleep, anxiety around bedtime, which resulted in an increased irritability with others; (2) Avoiding travelling in any form of transport, which resulted in her relying on others to take her children to school and other social or sporting events; (3) Withdrawing from friends and family, which led to her isolating herself socially. She believed that if she avoided all forms of transport and stayed inside, she would reduce the chances of experiencing any flashbacks or “getting very panicky” which she found extremely distressing and frightening. T and the therapist created a Problem and Goal form to capture this information (Appendix C) and agreed to discuss the problems and goals again when the treatment plan was formulated.

The specific client issue selected is Post Traumatic Stress Disorder (PTSD). PTSD is defined as “a common anxiety disorder that develops after exposure to a terrifying event or ordeal in which grave physical harm occurred or was threatened” (DSM-IV-TR: 463). The DSM-IV-TR’s criteria are precisely written as: exposure to a traumatic event, persistent re-experience of the event, avoidance of the stimuli, persistent avoidance of increased arousal, duration of disturbance and impairment of social occupational or other important areas of functioning. Within the criteria there are subsets portraying greater detail of the types of symptoms that may be experienced by the client (Appendix A).

T was seen over a period of 13 sessions. The duration of each session lasted between 1 hour and 90 minutes. Longer sessions were included to provide sufficient time for sharing the trauma history and allow time for anxiety levels to decrease (Leahy and Holland, 2000, p197).

The contract between the counselling service and T was explained. This included informed consent to tape sessions, confidentiality and its limitations and an evaluation of risk. Evaluation of risk is an important part of the therapeutic process and is done throughout therapy. It involves assessing the client, the environment and also the therapists own personal and professional limitations (Mueller, et al. 2010, p 65). CORE OM was used to calculate a risk score and also to assess T’s suitability for therapy. The Cognitive Therapy Rating Scale as developed by Safran and Segal was not available to the therapist during the first session, but subsequent reviewing of the scale indicated that T was a suitable candidate for cognitive behavioural interventions. CORE OM score is shown below in figure 1.

Prior to developing a treatment plan, the therapist socialised the client to CBT explaining the evidence that supported using CBT interventions for ASD. (Bryant, et al. 1999) and (Westbrook, et al. 2011, p81-83). First session therapist notes detailed T’s past history, the development of problems and the protective factors in her life (Appendix B). T was clear about what she wanted from therapy. Her problems fell into three main areas: (1) Nightmares, poor sleep, anxiety around bedtime, which resulted in an increased irritability with others; (2) Avoiding travelling in any form of transport, which resulted in her relying on others to take her children to school and other social or sporting events; (3) Withdrawing from friends and family, which led to her isolating herself socially. She believed that if she avoided all forms of transport and stayed inside, she would reduce the chances of experiencing any flashbacks or “getting very panicky” which she found extremely distressing and frightening. T and the therapist created a Problem and Goal form to capture this information (Appendix C) and agreed to discuss the problems and goals again when the treatment plan was formulated.

The therapist asked T if she could recall her most recent experience of a flashback (Figure 2a). T reported that the pattern of events leading to feeling panicked or experiencing a flashback were the same. She would make an effort to do a certain activity, but flashbacks and panic were triggered by (in particular) smells or sounds that could not be avoided. The hot cross bun formulation in figure 2a tracks events from leaving the house, hearing cars and smelling petrol, which was the trigger point. On this occasion T reported having a clear memory of being trapped in the car (which was also her recurring nightmare), she could remember smelling petrol and hearing the screeching of brakes. Her brain misinterpreted these signs for an actual threat, creating distorted thinking: “I’ve got to get home something terrible is going to happen”, hostile emotions; fear, anxiety and terror, unpleasant physiological reaction; heart pounding, shaking, feeling nauseous, which led to her avoidant behaviour to reduce her anxiety and escape her perceived fearful situation.

Flashbacks are defined in DSM IV as a “recurrence of a memory, feeling, or perceptual experience from the past” (American Psychiatric Association,1994). Another example of a flashback involved T sitting in her garden when a neighbour was mowing the lawn with a petrol engine lawn mower. T could smell the petrol and this triggered a flashback to the events of the RTA. The therapist encouraged T to follow the formulation and create her own diagram based on her experience in the garden (Figure 2b). T and the therapist were able to look at both diagrams and see that the pattern was similar. A sound or smell was identified as the trigger in both examples. Her thought process, affect and physiology were similar, but crucially, this led again to her avoidant behaviour.

Hot Cross Bun Formulation

Event/Trigger:

• Walking to the shop to buy milk, hearing
• the cars and smelling petrol
• Flashback of being trapped in the car

Thoughts:

• I’m going to die, I’ll never see me children again
• I’ve got to get away from here
• I’ve got to get home, something terrible is going to happen

Behaviour: Emotions:

• Escape the situation Fear
• Tearful Terror
• Anxiety

Physiology:

• Heart pounding, Nausea,
• Tense, Sweating, Shaking
• Based on Hot Cross Bun (Padesky, 1993)

Hot Cross Bun Formulation (originally hand drawn by client)

Event/Trigger:

• Sitting outside in the garden, having a cup of tea
• Hearing neighbour start up his lawn mower
• Smelling petrol from the lawn mower
• Flashback of fear of being burned alive

Thoughts:

• Oh God! It’s happening again
• I’ve got to get inside the house. I’ll be safe there

Behaviour: Emotions:

• Tearful Fear
• Needing to get inside the house Terror
• Anxiety

Physiology:

• Heart pounding, Nausea,
• Tense, Sweating, Shaking,
• Based on Hot Cross Bun (Padesky, 1993)

T and the therapist discussed the process of recording details in this format and agreed that it gave them both a greater understanding of T’s situation. This collaborative approach is characteristic of CBT and was necessary when working towards a treatment plan for factors that needed to be targeted in therapy and homework setting. Padesky and Greenberger (1995, p6) explain the importance of the client and therapist working as a team, particularly as clients may have an expectation that the therapist is going to “fix” them. Milton (2009, p104) agrees adding that the therapist also plays the role of a trainer, encouraging the client to become an observer of themselves in order to challenge their thoughts, feelings and beliefs. Westbrook et al (2011, p238) cites Kazantzis et al (2002) in providing evidence of greater improvement in those clients who complete homework. T was keen to monitor any anxiety provoking scenarios at home using the hot cross bun model. She was aware that if her second goal was to be achieved (Appendix C) she needed to reduce and eventually eliminate her avoidant behaviour (Wells, 1997, p49-50).

A treatment plan was discussed and agreed with T based on her problem list and goals for therapy (Appendix C). The treatment plan included the following elements:

• Pyscho-Education
• Grounding and Safety Work
• Imaginal Exposure Therapy
• Cognitive Restructuring
• Relapse Management

The session on psycho-education gave T the opportunity to learn about her symptoms, and to recognise and anticipate them for effective management. Fisher, (1999) states that psycho-education is an essential element for stabilising a trauma client. Briere and Scott (2006, p87) agree, adding that psycho-education provides the client with accurate information about the nature of their trauma, which gives them a greater understanding of their situation. Psychoeducation involved justification of use of IET, a history of our learning experience and the fight or flight response. Regular reference was made to the client’s formulation so that she could understand how and why her threat response had been activated.

Once T understood her anxiety response in relation to her experiences, she felt ready to continue onto the next stage of therapy. Grounding and safety work was completed prior to IET. Herman (1997, p155) argues that the central task of the first phase of trauma therapy must be safety. The client needs to feel safe within themselves; learning grounding and safety skills gives the client the opportunity to manage potential uncontrolled flashbacks. This also formed part of T’s relapse management in the later stages of therapy. Once safety and grounding work was completed, the therapeutic process moved onto the trauma itself using IET.

Throughout therapy there were opportunities to explore T’s present situation and past events. This information was initially written down in a mind map format and shared with T during the session. As additional information was gathered in subsequent sessions this was written in longitudinal format (Figure 3). From the information gathered, the client recognised how and why she had always been the “rescuer” in the family. This included an age inappropriate responsibility when her father had left the family home and T had taken on the role of carer to her distraught mother and siblings. She suffered an emotional breakdown at the age of 14, over whelmed by the pressure of doing well at school so that she could get a good job and support the family. T recognised how this belief system developed after her father left and how it was effecting how she saw herself in the present. During therapy T and the therapist discussed the importance of this belief and how it had allowed her to cope during those years growing up. The therapist asked what purpose this belief served in her life now when she was happy with her family and well supported by her husband. She no longer needed to be the “rescuer”. T and the therapist explored how this belief may be affecting what was happening to her when she was fearful of having a flashback. T concluded that she needed to add “I must always cope” to her beliefs in Figure 3 and “I can’t cope” to her thought process. T recognised the contradiction between this thought and her “rescuer” belief.

Longitudinal Formulation

Early Experiences

• 5 years old, Dad leaves family home
• Oldest of four children, Takes on a helping role
• Later supports mother through depression
• Breakdown at school aged 14 years due to self- imposed pressure
• Met future husband aged 16,Pregnant at 17 years and married at 18 years old

Beliefs

• It’s my responsibility to take care of everyone and make things right
• I must always cope

Assumptions and Rules

• I must be perfect and do everything right, otherwise I will let everyone down
• If something goes wrong it will be my fault

Critical Incident

• Car Accident

Activation of Beliefs

• It’s my responsibility to save everyone

Automatic Thoughts

• I should have got B out of the car. I didn’t do everything I could have
• I failed. I can’t cope with this

Behavioural Emotions:

• Avoidance Fear
• Social withdrawal Anxiety
• Fearful to go outside Guilt
• Fearful to travel in any transportation
• Worry

Physiology

• Poor Sleep – Tense – Heart Pounding – Sweating

The goal of IET is to expose the client to the memory of the trauma rather than to relive the trauma itself. T’s therapy involved her retelling the story initially in the past tense and then in the present tense. An important part of the healing process was encouraging T to bring those traumatic memories to mind, in a safe and trusting environment, while remaining in the present. The client learns through repetitive description, that the memory of the event is not dangerous and will also allow habituation to take place (Zayfert and Becker, 2008, p127). T decided that she would record the sessions on the voice recorder section of her mobile phone and listen to the recordings at home as part of her homework. Zayfert and Becker (2008, p130) emphasise how critical listening to the tapes at home is as the repetition is vital if the exposure is going to be successful.

The therapist explained that T would be asked to close her eyes and describe the events of that day. Leahy and Holland (2000, p 198) suggest breaking the clients story down into smaller parts if there are a series of traumatic events. T was asked to recall the events of that day in terms of chapters; several chapters were listed (Appendix D). T’s experienced anticipatory anxiety at the thought of retelling the story and this was discussed. The therapist reassured her she would be experiencing the memory, that the RTA was not happening right now and that she was safe in the room and could open her eyes at any time. T began at a point in time when she felt safe and ended the narration at a point in time when again she felt out of danger. The therapist explained the Subjective Units of Distress (SUDS) Rating Scale and then T began narrating her story in the past tense and was allowed to do this uninterrupted; the therapist only intervening to check on T’s anxiety. T’s SUDS score was noted for each chapter (Appendix D – col A). At the end of each session, T was given time to process her experience before leaving. T gave the therapist feedback on how she felt sessions had gone, and what, if anything she had learned.

The next session involved the client narrating the story, but this time in the present tense. T found this difficult at first and often resumed the past tense. T and the therapist had discussed the likelihood of this happening and T agreed that the therapist would prompt her to return to the present tense. SUDS scores were again noted (Appendix D – col B). T reported being surprised at the change in scores from the previous week. There were certain sections of the story that T found very difficult to narrate; these sections were narrated without much detail. After discussing this briefly, T and the therapist listened to the recording of the present tense narration. T recorded SUDS levels herself (Appendix D col C) and once complete, the three SUDS scores were examined and discussed. T noted how scores had both increased and decreased from first narration to second narration, but that all scores had reduced on her first listening to the tape. T was then asked to grade the chapters and chose five (the most anxiety provoking) to work on. The five chapters were listed chronologically (figure 4) and then in order of their anxiety rating (figure 5). For the next five sessions each chapter was narrated and listened to repeatedly until T’s SUDS rating had dropped; starting with the least and working towards the most anxiety provoking. The therapist asked questions relating to the clients senses and emotions and physiology so that her memories were fully activated (Leahy and Holland, 2000, p197). To T’s surprise, narrating in the present tense and sensory questioning produced additional memories that T had not remembered in the previous narrations.

Figure 4 – Chronological Order

1 Car flips over – upside down – smell of petrol

2 Wood coming towards the car

3 The car door won’t open (T’s recurring nightmare)

4 B is not moving

5 G is screaming at T to get them out of the car

Figure 5 – Order of Severity – Least to Worst

5

4

3

2

1

Wood coming towards the car

Car flips over – upside down – smell of petrol

G is screaming at T to get them out of the car

The car door won’t open (T’s recurring nightmare)

B is not moving

The therapist noted the five chapters as “hot spots” (Figure 6) and asked T what her thoughts were when she brought the scene to mind. These were also noted together with the emotion that went with them.

The therapist was able to challenge T’s distorted thoughts through cognitive restructuring which included her “rescuer” belief that she was somehow responsible for getting everyone out of the car that day. Once SUDS levels had been reduced for all five chapters Appendix E), T was able to say out loud her re-evaluation statement for each chapter – accepting and believing it.

Fig 6

Re-Evaluation of Peak Experiences

Hot Spot Thought – Belief Emotion Re-Evaluation

The car has flipped “I’ve survived the crash Fear “I did not burn to death.

Over onto its top; there but now I’m going to burn I did not die, I did survive

Is a smell of petrol to death” the experience and I am safe now.

It’s over.” THIS IS A FACT

Wood from a fence is “The wood is going to hit Fear “The wood did not hit me or anyone else.

Flying towards the car me. I’ll never see my boys I did survive the experience. I am safe.

again.” My children are safe. It’s over.

THIS IS A FACT

The car door won’t open. “It’s not going to open, Terror “I was not trapped. I did get out of the car.

It just won’t budge at all I’m trapped.” I am not trapped now, I am safe now.

It’s over.” THIS IS A FACT

B goes limp and his head “Oh my God! B is dead” Terror “B did not die. He did survive the accident

Falls forward He is safe now. It’s over. THIS IS A FACT

Sister G screams to T to “I must break the window. Fear “We all got out of the car. We did not die.

Get them all out of the car I have to get us all out. We are all safe now and it’s over.”

If I don’t break the window THIS IS A FACT

We’re all going to die”

Outcomes and Personal Reflection

T’s post therapy CORE score of 31 (figure 7) represents a mean score of 0.912 (9.12) and falls within the healthy range of the Core measure. As there is a mean difference of over 5, this, according to CORE measurement indicates a clinical and reliable change (CORE ims).

Fig. 7 Core OM Results – Pre and Post therapy

Pre Post

Well Being 14 06

Functioning 21 05

Risk 02 00

Problems 42 20

Total 79 31

T’s presentation improved in the finals stages of therapy. Her cuts and bruises had healed well and she was no longer suffering with TMJ. T reported healthier sleeping patterns, but still with occasional dreams. She believed that she had spent so much time listening to her chapter on being trapped in the car that she became “fed up” of listening to it, rather than it provoking any anxiety. She was able to travel as a passenger in a car, and also to drive the car herself, but did not feel ready to drive on her own in the car. As a result understanding her an