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The aim of this assignment is to discuss the role of assessment in formulation with reference to Cognitive Behavioural Therapy (CBT). CBT is one of the best researched therapies and views problems as arising from beliefs and patterns of behaviour which are learnt across the course of a person’s life (Health and Social Board, 2015). According to Beck et al (1993) the cognitive approach is best viewed as the application of the cognitive model of a particular disorder with the use of a variety of techniques. Assessment data is collected to obtain a diagnosis and develop an individualised formulation (Persons, 2012).
This assignment will discuss the aims and purpose of assessment, highlighting the importance of formulation and treatment, while recognising the potential challenges faced by the therapist.
Lastly, this assignment will review the concepts of diagnosis and formulations in mental health. Looking at how understanding the persons own characteristics to their difficulties are important and describes the concerns around using diagnosis alone to select clinical interventions.
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CBT is based on the cognitive model of mental illness which was initially developed by Beck in 1964. It is most commonly used to treat anxiety and depression, but has been used to help other mental health and physical problems (NHS, 2016)
An essential part of the assessment is the process of data gathering, which is important to identify the client’s problems and also gain their collaboration and trust. True to the principle of collaborative empiricism, the assessment needs to be a process of joint discovery (Corrie et al, 2016). Communication is therefore a key element in assessment. According to Beck (2016) a strong therapeutic alliance is essential to treatment. CBT assessments primarily focus on a detailed description of the current presenting problem. The process of assessment is multifaceted and includes socialising the client to the CBT model while building a therapeutic alliance and assessing the client’s motivation for change (Mitcheson et al, 2010). Psychology research has demonstrated the importance of the relationship between client and therapist (Safran, 2018). The client may find it difficult to establish a therapeutic relationship. According to Vernon and Doyle (2017) without attaining a close relationship the client would most likely not listen to the therapist and fail to benefit from therapy.
Assessment in CBT is to gain an understanding of the client’s current life difficulties and problems by using a planned, structured and systematic approach (Hughes et al, 2014) which is crucial for formulation and conceptualising the client’s problems. It is also an opportunity to engage and socialise the client in the CBT approach.
Key areas of assessment include the cross sectional and the longitudinal elements. The five area analyses, also known as the ‘Hot Cross Bun Model’ are frameworks for developing a cross sectional understanding of the client’s problems. These frameworks can be used to plot the links between negative automatic thoughts, emotions, physical sensations and behaviour (Hughes et al, 2014). According to Williams and Garland (2002) the five area analyses aims to communicate fundamental CBT principals and key clinical interventions in a clear language.
CBT can be applied longitudinally to explore the origin of beliefs, rules and assumptions which shape an individual’s world views (Whalley, 2018). According to Rathod et al (2015) the longitudinal assessment explores the developmental history and helps the individual understand the biological, psychological and sociocultural factors which may have played a role on the onset of the symptoms and the maintenance. The core components of a longitudinal assessment include: personal, work, social, family, medical, spiritual, forensic and sexual history.
According to Corrie et al (2016) addressing the question of suitability is important during the assessment and formulation phases as there are clinical, ethical and economic reasons for suitability. Not everyone finds CBT helpful. Individuals may feel uncomfortable or distressed thinking/talking about their anxieties and emotions, may also find it difficult to commit the time to complete the exercises outside of the sessions (Mind, 2015). As suggested by Myhr et al (2017) clients ill-suited for CBT risk having negative experiences in treatment and predicting who will benefit from CBT is an ongoing challenge for the therapist.
The assessment is an ongoing process throughout the entire therapy. With the therapist trying to make sense of the information while building up tentative ideas about what processes might be important in the formulation (Westbrook el al, 2011).
Formulation sometimes referred to as a Case Conceptualisation is an element of an empirical hypothesis –testing approach to clinical work that has three key elements assessment, formulation and intervention (Eells, 2007). Case formulation guides a therapist how to structure the sessions and by prioritising the client’s problems. It is referred to as a CBT keystone and is considered essential to the practise of CBT. According to Persons and Thompkins 2007, cited in Eells, 2011) the information obtained during the assessment is used to develop a formulation. Formulations look at the life experiences of a distressed person and the meaning they make out of these experiences (Johnston and Dallos, 2014).
The process of case formulation starts with an unstructured ‘problem list’ (Persons, 1989), then proceeds to look for common themes which could suggest underlying beliefs, schemas and early life experiences.
Formulations can be developed using different formats and normally consists of a number of stages. Johnstone and Dallos (2014) suggest a framework for formulation which refers to the levels and process of formulation in regard to the five Ps; presenting issues, predisposing factors, precipitating factors, perpetuating factors and protective factors. Kuyken et al (2009) states that the formulation is the heart of evidence-based practice and from the research evidence the therapist views the formulation as an important part of treatment. However, Johnstone and Dallos (2014) argue that formulations of each individual have to be taken with care since they are hypothesis and not statements of fact.
Formulation guides treatments by identifying the targets of treatment, which are normally the mechanisms that the formulation proposes are carrying the symptoms (Persons, 2012).
Corrie et al (2016) suggests that the assessment and formulation are the backbone of CBT, however knowledge of the many ways of carrying out these activities is lacking. Westbrook et al (2011) state CBT involves a range of concepts, theories, models and styles of working, rather than a single discipline. Corrie et al (2016) state many individuals with the same problem are not a homogeneous group therefore therapists face an unending series of choices about what direction to take. Empirically Supported Treatment does not always address the therapist’s needs as individuals typically have multiply related disorders and problems that can affect one another (Persons, 2012).
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Volungis (2018) states towards the end of the formulation a diagnosis needs to be provided. According to Norman and Ryrie (2013) though medical diagnosis is important we need to comprehend the nature of a person’s problems and the effect it has on their functioning. Corrie et al (2016) states diagnosis can inform and complement formulation by providing nomenclature that can guide individuals to relevant treatments. However, Newell and Gournay (2009) state that a diagnosis tells us little about the individual and nothing about the context and impact of their difficulties. MacNeil et al (2012) states that diagnosis may instruct us poorly about which form of intervention we should undertake as individuals may experience a diversity of etiological factors. Due to the limitations of diagnosis in mental health, the concept of case conceptualisation has attracted interesting interest, and can be used as a bridge between assessment and treatment (Kuyken et al, 2009).
CBT assessments are used to gather information and test out the key hypothesis of a CBT formulation so that we end up with a model that is based on evidence and makes sense to both the client and the therapist. The CBT formulation aims to provide a concise description of the key features of a problem, how it got started and what keeps it going (Kennerley et al, 2016). However, therapists may face challenging situations throughout the process due to the range of concepts, theories, models and styles of working. Corrie et al (2016) state there is a lack of consensus about how to assess and formulate client’s needs. Persons and Lisa (2015) emphasise diagnosis is important for several reasons including that much of the scientific and treatment literature is based on a diagnosis. In spite of the main approach still being a medical one, formulations are starting to play a part in treating people with mental distress. MacNeil et al (2012) suggests that if done well, formulation provides an opportunity for a shared understanding of a person’s difficulties in ways that a diagnosis alone does not achieve.
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